Stress Fractures

Campbell Clinic has recently seen an increase in stress fractures in the female high school cross country runner which has raised concerns and propelled this public awareness notification to address some of the issues dealing with increased risk factors associated with stress fractures and ways to potentially prevent stress fractures from occurring.

Studies have shown that female athletes have a significantly higher overall prevalence of stress fractures than their male counterparts. This can be attributed to many factors which include:

  • Puberty: Puberty is an important time for bone mineralization. Stress fractures have been reported to occur in 49% of women runners with a history of irregular menses compared and in 29% of those with a history of regular menses.(Barrow). Peak bone mass in women is achieved by early 20’s and is a strong predictor for long-term risk of osteoporosis. (Kanis and Eastell)
  • Diet: Nutritional deficiencies contribute to decreased bone mass density (BMD). Poor caloric intake needed for the energy expended seems to be a primary factor that predisposes female athletes to menstrual dysfunctions resulting in detrimental effects to bone health.
  • Poor fitness: Training resumed after significant inactivity or injury. Sedentary lifestyle does not allow for a proper physical fit foundation to be layed in preparation for sporting activities.
  • Training errors: Increasing mileage to rapidly.
  • Biomechanical: Pronated (flat) feet, increased Q angle and fore foot varus, and leg length descrepencies can contribute to stress fractures.
  • Running gait: Running gait patterns can be affected by muscular fatigue, muscle tightness, or minor injury which could result to placing increased stress on bone structures.
  •  Training surface: Running on poor surfaces or too much hill running can lead to increase risk of stress fractures.
  • Poor shoes: Proper shoe selection is important

Prevention and awareness are key in being vigilant in dealing with stress fractures. It would be ideal for the cross country high school female athlete to have a complete biomechanical evaluation performed by a physical therapist determining any specific weakness or inflexibilities along with determining the proper shoe for the specific runner.

Secondly, the coaches assuring that each runner has a good running foundation prior to starting the season and having a good understanding of the over training factor involved with stress fracture and progressing the training appropriately for each individual athlete. In our professional opinion, one tempo run, and one speed workout a week is sufficient for building speed while one longer run a week with two regular runs a week and cross training such as swimming or biking are sufficient for building cardiovascular endurance. A core stability program along with a thorough stretching program are also pertinent to success against injury.

Thirdly, parents’ being aware of their child’s nutritional intake is vital. This involves enough good caloric intakes for the energy needed. Ideally, this would be accomplished through meals that are balanced with whole grains, fruits, vegetables, and protein and with additional supplements of calcium with vitamin D, copper and magnesium. Caffeine, foods/drinks high in sugar, and foods high in fat should not make up a regular diet plan.


Osteoporosis is epidemic in the United States. Statistically, One in every two women and one in every four men aged fifty or older will suffer an osteoporosis related hip, spine, or wrist fracture during their lives. As the disease progresses, bones can become so vulnerable that fractures can occur spontaneously or through such mild trauma as opening a jammed window, lifting a light object from the floor with a rounded thoracic spine or even just coughing and sneezing.

Osteoporosis is the gradual and silent loss of bone and is not to be considered a normal aging process. Osteopenia is mildly reduced bone mass - a loss of approximately 10% - 20% of bone mass indicating the onset of osteoporosis.

Osteoporosis was not recognized as a disease until 1994 and is known as the silent disease in that it is not recognized until major changes have occurred such as height loss or an increase in kyphosis. Pain is not always an indicator either. Pain may only occur in the hip after a fracture has occurred.

There are numerous risk factors that contribute to osteoporosis – it is no longer considered limited to the stereotype thin Caucasian female. Medications, caffeine, soda, alcohol, cigarettes, thin, obese, too much exercise, not enough exercise – all could be contributors. All this to say, looks are deceiving and more people may have osteopenia/ osteoporosis than thought. A Bone Dexa Scan is required of the lumbar spine and femur to make an official diagnosis of osteopenia/ osteoporosis.

There is hope however. Just because an individual has been diagnosed with osteopenia does not mean they will develop osteoporosis and those with osteoporosis can prevent further bone loss and actually increase bone mineralization. This can be accomplished through proper medication if indicated, good nutrition, exercise, and postural education.


A doctor specializing in osteoporosis is required to determine if medication is indicative for an individual.

Nutrition – a nutritionist/ dietician would be an appropriate consult to determine nutritional needs are met. The bottom line on nutrition; however, is that an individual is getting 1500 mg of Calcium a day and Vitamin D. Natural sunlight is considered the best way to receive Vitamin D. It is recommended sunlight two times a day for fifteen minutes 3 – 4 times a week.


It is recommended that an individual be on their feet at least four hours a day to prevent bone loss. Inactivity is a strong contributor to bone loss. It is also recommended that an individual walk at least four days a week for exercise to stimulate bone and to perform specific strengthening exercise to promote increase muscle strength which in turn strengthens bones.

Postural Education

– It is important that an individual be educated in specific postures to avoid that may contribute to fractures. Postures that involve trunk flexion or twisting should be avoided. For instance, one should log roll to get out of bed instead of just sitting straight up from a supine position.

Fundamental Fitness is a wellness and prevention studio with personal trainers with Physical Therapy backgrounds available to guide, direct, and educate individuals on specific exercises for osteoporosis, how to start a walking program, and postures to avoid that may contribute to fractures. Fundamental Fitness can be contacted via email at, or phone (901) 275 – 8060 and is located at 5545 Murray Rd Suite 150 in East Memphis.

Article written by Nanette Farris PT – a Physical Therapist for 18 years and owner of Fundamental Fitness.


This article was featured in Flex Magazine. It was written by Bob Lefavi, and Timothy C. Fritz. Bob Lefavi, PhD, is an assistant professor in Georgia Southern University's graduate health science program, located at Armstrong State College, Savannah, Georgia.

The Metabolic Spark Plugs

One of the most confusing issues for any athlete is supplementation. What to take, how much, when to take it, blah, blah, blah. Figuring out a supplementation regimen can be so frustrating at times that it becomes easy to lose sight of the forest for the trees, to forget the purpose of supplementation and to overlook exactly what makes successful bodybuilding. It's sometimes easy to forget that the cells in our bodies, particularly muscle cells, rely on certain biochemical reactions for proper metabolism, growth and maintenance. These reactions, in turn, depend upon specific vitamins to help catalyze, or facilitate, their actions.  Without these vitamins, nothing happens. Even if only one of these critical substances is deficient, a bodybuilder's progress can be stifled without warning. Virtually every energy production or muscle growth process we rely on so heavily (and that we sometimes take for granted) is dependent upon, in one way or another, a vitamin.  Making matters more critical is the fact that bodybuilders are notorious for overlooking vitamins because these nutrients don't supply energy like carbohydrates, proteins and fats do. But that doesn't mean they aren't important. Without vitamins, muscle mass would decay, bone density would deteriorate and all systems of the body would begin to fail.

Vitamin Variables

Vitamins can be divided into two broad categories: fat-soluble and water-soluble. Fat-soluble vitamins (A,D,E, and K) are so named because they are stored in the body's fatty tissue and do not have to be replenished daily. But be careful: Because they are stored, overdoes of these vitamins can lead to toxicity.  The water-soluble vitamins (with the exception of vitamin C) are composed entirely of the B and B-complex vitamins, including Thiamine (B1), Riboflavin (B2), Niacin (B3), Pyridoxine (B6), Folate, Cobalamin (B12), Biotin and Pantothenic Acid. Because these vitamins are water soluble and thus have difficulty entering fatty tissues, they aren't stored in the body and excessive amounts are excreted. And while this means toxicity is generally not a problem, these vitamins must be continually included in a bodybuilder's diet. This is Flex Magazine's Top 10 Vitamins for Bodybuilders, in reverse order.

10. Cobalamin (vitamin B12)

Although the functions of vitamin B12 are numerous, those important to bodybuilders include carbohydrate metabolism and maintenance of nervous system tissue (the spinal cord and nerves that carry signals from the brain to muscle tissues). Stimulation of muscles via nerves is a critical step in the contraction, coordination and growth of muscles.  Vitamin B12 is available only from foods of animal origin; therefore,it is very important for athletes following a strict vegetarian diet to consult a physician about vitamin B12 supplementation. In fact, B12 shots are popular with countless athletes, vegetarians and nonvegetarians alike, many of who swear it helps them perform better.

9. Biotin

Although there's a limited amount of sports nutrition research on Biotin, it makes our top 10 list because it has critical functions in amino acid metabolism and the production of energy from many sources. It also may be one vitamin that some bodybuilders have trouble when attempting to maintain an adequate supply.  The reason bodybuilders may have difficulty with Biotin is because it can be blocked by a substance called Avidin. Avidin is found in raw egg whites, a staple for many athletes. In fact, bodybuilders who eat raw egg whites or who don;t cook egg white well enough may experience growth problems with Biotin deficiency if their egg white consumption approaches 20 per day. Eating raw eggs can also lead to a bacterial infection called Salmonella, which can have severe health consequences.

8. Riboflavin (vitamin B2)

Riboflavin is involved in energy production in three areas: 1) Glucose metabolism, 2) Oxidation of fatty acids, and 3) The shuttling of hydrogen ions through the Krebs cycle. Of particular interest to bodybuilders, Riboflavin is somewhat related to protein metabolism. In fact, there is a strong relationship between lean body mass and dietary riboflavin.  One study by Belko and colleagues found that females needed higher than RDA levels of Riboflavin to return blood levels of Riboflavin to normal after exercise. Another study by Haralambie showed that Riboflavin supplementation improved muscular hyperexcitability (seen in trained athletes). This vitamin may prove to be especially important for athletes.

7. Vitamin A

Most of us know that vitamin A helps with vision, but bodybuilders need to become familiar with its other benefits. First of all, vitamin A is important in the synthesis of protein, the chief process of muscle growth. Second, vitamin A is involved in the production of Glycogen, the body's storage form of energy for high intensity performance.  The problem with vitamin A status in bodybuilders is twofold. First, American diets are consistently measured to be low in vitamin A. Second, both strenuous physical activity (which disrupts the absorption of vitamin A) and a low fat diet (which renders vitamin A loss in feces) jeopardize the level of vitamin A in the body. So be especially careful of your vitamin A intake during contest preparation.

6. Vitamin E

Vitamin E is a powerful antioxidant, meaning it protects the cell's membranes. This is important because many of the metabolic processes that take place in the body, including the recuperation and growth of muscle cells, are dependent upon health cell membranes.  You've probably heard a lot about antioxidants in the news lately, and research continues to validate their importance. Specifically, antioxidants help to reduce the number of free radicals in the body. Free radicals are natural byproducts of cellular respiration, but accumulation of free radicals can lead to cellular changes and destruction (even cancer), rendering cells unable to adapt normally. This means a reduction in exercise induced processes in the cell such as repair and growth.

5. Niacin (vitamin B3)

This vitamin is involved in nearly 60 metabolic processes related to energy production and ranks high for bodybuilders by virtue of its critical importance in providing training fuel (no train, no gain)! The bad news is that high levels of Niacin have been found in the blood of athletes after exercise, suggesting that athletes may need more niacin than nonathletes. On the other hand, the good news is that even if a diet is low in Niacin, the body can make it from the amino acid tryptophan, which is found in abundance in turkey meat.  Bodybuilders are familiar with the form of Niacin known as nicotine acid, which causes vasodilation and may help a competitor look more vascular before going onstage. But this form of Niacin shouldn't be used during training; large doses of nicotinic acid (50 - 100 mg) significantly impairs the body's ability to mobilize and burn fat.

4. Vitamin D

Vitamin D plays a crucial role in the absorption of Calcium and Phosphorus. Calcium is necessary for muscular contraction. If adequate stores of Calcium are not available in the muscle, full, hard muscular contractions cannot be sustained. Of course, Calcium is also needed for the integrity of bones, which must support increased muscle tissue and provide an anchor during muscular contraction.  And don't forget about Phosphorus. Phosphorus helps provide quick, powerful muscular contractions, which comprise the majority of movements during weight training. Phosphorus is also required for the synthesis of ATP (Adenosine Triphosphate), the high energy molecule used by your muscle cells during contraction.  This nutrient is high in the list since bodybuilders typically avoid the fat content, e.g., dairy foods. Look for vitamin D fortified foods and get in the habit of drinking at least one glass of low-fat or nonfat milk per day.

3. Thiamine (vitamin B1)

This B vitamin packs muscle! Thiamine is one of the vitamins required for protein metabolism and growth. It's also involved in the formation of hemoglobin, a protein found in red blood cells that transports oxygen throughout the body (especially working muscles). The transport of oxygen is critical to athletic performance and becomes even more important as intensity and duration of exercise increase.  Making matters more interesting, Thiamine, according to research, is one of the few vitamins that enhances performance when supplemented and is increasingly needed by athletes. Not only that, but Thiamine requirements appear to be directly related to caloric expenditure. The more exercise frequency, intensity and duration increase, the more Thiamine is needed.

2. Vitamin B6 (Pyridoxine)

Protein metabolism, growth and carbohydrate utilization are all made possible in part by the presence of vitamin B6. Like Thiamine, studies on Pyridoxine in athletic performance show a definite increased need for athletes and possible performance enhancement from supplementation.The vitamin makes the number two spot for a very good reason: It's the only vitamin directly tied to protein intake. The more protein you eat, the more Pyridoxine you need. Of course, this, coupled with Pyridoxine's role in growth, had profound implications for bodybuilders, though it is generally not known or discussed in sports nutrition circles.

1. Vitamin C (Ascorbic Acid)

Surprised? Most athletes don't realize how important vitamin C status is to success. As the most widely studied vitamin in sports nutrition, Ascorbic acid has proven itself to be valuable to bodybuilders in many ways.  First, vitamin C is an antioxidant, protecting muscle cells from free radical damage, thus enhancing recovery and growth.  Second, Ascorbic acid is also involved with amino acid metabolism, especially the formation of Collagen. Collagen is the primary constituent of connective tissue, the stuff that holds your bones and muscles together. This may not seem important, but as you lift heavier weights, the stress you put on your structure becomes tremendous. If your connective tissue is not as healthy and strong as it should be (a problem often seen in steroid users), risk of injury dramatically increases.  Third, vitamin C helps in the absorption of Iron. Iron is necessary to help Oxygen bind to hemoglobin in blood. Without adequate oxygen transportation in blood, muscles are robbed of precious oxygen and performance is greatly reduced.  Fourth, Ascorbic acid also assists in the formation and release of steroid hormones, including the anabolic hormone testosterone.  Finally, vitamin C is perhaps the most water soluble vitamin there is. In other words, it diffuses very rapidly in water. Since a muscle cell is mostly water, the more muscular an athlete becomes, the more vitamin C disperses and the lower the concentration of this critical substance becomes in body tissues. So vitamin C requirements are greatly increased for bodybuilders.

Training Misconceptions

"Will I get too big if I strength train?"

This is the number one objection that women have with respect to strength training or lifting weights.  The answer is NO...

The rate at which you lose fat is far greater than the rate at which you can gain muscle.

Fact #1 You can gain only about .5 to 1.5  pounds of muscle per month.  Probably closer to .5 pounds of muscle.

Fact #2 You can lose about 4 to 8 pounds of fat, not water weight, per month.

If you do the math, you should still be losing body weight.  Take the maximums, a person loses 8 pounds of fat in a month, but gains 2 pounds of muscle in a month; that person would have lost 6 pounds of bodyweight.

If you're not losing body weight, then you're probably not eating right, or not doing enough cardio.

So, in time, your body should be shrinking, not getting "bigger".  If you are eating properly and training smart, you should still be losing inches off your waist and hips.


"Women should do Pilates, Yoga, and Cardio to lose fat"

It seems that the weight-lifting room is 70% male and 30% female.  Why is this?  Shouldn't it be split evenly?  Well, there are a few reasons why this occurs:

Some women don't lift weights because they get tired of men hitting on them at the gym.

Some women report feeling intimidated by the men or feel intimidated by women who are in great shape.

Some are unfamiliar with the equipment.

Ok, this I can understand.  All three are legitimate concerns.

It can be annoying for a woman to consistently get hit on by men... Unfortunately, this is something you just have to put up with if you are a woman.  Guys try to leave the women alone *laughing to myself*...

Next point, woman, you can wear a hat and headsets. That's kind of like a "Get Lost" sign for men.  I would never talk to a woman that had a hat and headsets on...

As far as being intimidated and unfamiliar with the gym itself, you might want to get one of the trainers at the gym to show you around.  Usually when you join a new gym, you receive a free session or two with a trainer, use them.  Have them show you how to use the equipment.  This way it won't seem so foreign to you.  Once you start getting into a routine, you probably won't have that feeling of intimidation any longer.  Also, if you still feel intimidated, hire a trainer.

Let's go back to the initial misconception I was addressing, "Women should do Pilates, yoga, and cardio to lose fat".  What is the best way to increase your metabolism? Build more muscle.  And the #1 way to increase muscle and shape your body is "strength training" (lifting weights).  Pilates and yoga are great, but it all comes down to your goals.  What is your goal?  Is it flexibility, spirituality, or simply just toning?

Pilates is good for flexibility and some muscle gain.  Yoga is great for flexibility, breathing, reducing stress and it can also be a spiritual experience.

But, what is your primary goal?  If it's to lose fat and gain muscle (Tone), then the answer is and will always be strength training, diet, and cardio.  This combination will give you the fastest results in the least amount of time.


Spot Reduction

"If I do more abs exercises, can I lose abdominal fat?"

I'm sorry, the answer is a resounding NO.  Beware of the infomercials... They are lying or are just simply misleading.

It's very simple, the fat that covers your abs is related to how much body fat you have on your body.  If your body fat is 30% you will never see your abs.  If your body fat is 12%, you will see your abs.  It's that simple...  So, what is the best way to lose body fat?  Strength training, cardio, and diet.



"Men do arms and chest, women only need to workout legs..."

It seems that men have a bad tendency to have "Mirroritis".  I define "Mirroritis" as working out only muscle that you can see in the mirror.  For men, it's working out to much chest and arms and not enough legs and back.


Common Mistakes

Why don't people succeed?

A few reasons:

  • Not keeping a workout journal or a food journal.
  • Never going to the point-of-exhaustion, or close to it.
  • Not increasing the weights every week (or every 2 or 3 weeks).
  • Training inefficiently
  • Not applying "change" to a workout routine. Change weight lifting and cardio workouts every 4 to 8 weeks.
  • Lack of sleep.  I would recommend sleeping 8 to 10 hours a night.  For some, I know that might sound like a lot.  But if you're really serious about changing your life and your body, you will change your sleeping habits.  Sleep is critical.  Why?  When we sleep our body repairs itself which allows you to be 100% ready for the next workout.  When you workout at 80% or 50% due to lack of sleep, it will be extremely hard to lose fat and gain muscle compared to getting the proper amount of rest.
  • Not eating a health diet or simply eating way too many cheat meals.
  • Lack of cardio and strength training.
  • Making excuses...


Combat Fatigue

Fatigue and lethargy is one of the most common complaints amongst adult patients. If you have symptoms such as tiredness, fearfulness, allergies, frequent influenza, arthritis, anxiety, depression, reduced memory and difficulties in concentrating, insomnia, worn-out, inability to loose weight after extensive efforts, you may be suffering from adrenal fatigue (technically known as hypoadrenia).

Adrenal fatigue has a broad spectrum of non-specific yet often debilitating symptoms. The onset of this disease is often slow and insidious. Patients are told that they are stressed and need to learn to relax more. Yes, we all know that "stress kills" to a large extent. But, the question is how? And, what are the solutions?

The real truth is that stress is not a mysterious entity at all. Our body has a built-in mechanism to deal with it. Being able to handle stress is a key to survival, and the control center in our bodies is the adrenal glands. When our adrenal glands become fatigue and unable to handle stress, dysfunctional physiological smptomatology sets in.

Adrenal fatigue was first described in the medical texts in the 1800s as a clinical condition. It was one of the most prevalent conditions, afflicting almost every adult in one way or another. Despite effective diagnostic tools and treatment programs,  most conventional physicians were simply not informed and not prepared to treat adrenal fatigue as a serious threat to health. This condition was seldom diagnosed as a sickness for the past 50 years. Instead, it was considered as a condition whereby no treatment was available other than to tell the patient to "relax". Why was this so? The reasons were simple.  Laboratory tests were unable to detect any abnormality, until recently. Today,  adrenal fatigue could be accurately diagnosed, overcome and treated properly.

Adrenal fatigue should not be confused with another medical condition called Addison's disease where the adrenal glands are not functioning. While Addison's disease is often caused by auto-immune dysfunction,  adrenal fatigue is caused by stress. Adrenal fatigue is the non-Addison's form of adrenal dysfunction. Unfortunately, conventional medicine only recognizes Addison's disease as hypoadrenia, despite the fact that adrenal fatigue is a fully recognizable condition. As such, do not be surprised if your doctor is unfamiliar with this condition.

Signs and Symptoms of Adrenal Fatigue

Physical Therapy in Memphis Fatigue

· Tendency to gain weight and unable to loose it, especially around the waist.

· High frequency of getting the flu and other respiratory diseases and these symptoms  tend to last longer than usual.

· Tendency to tremble when under pressure.

· Reduced sex drive.

· Lightheaded when rising from a laying down position.

· Unable to remember things.

· Lack of energy in the mornings and also in the afternoon between 3 to 5 pm.

· Feel  better suddenly for a brief period after a meal.

· Often feel tired  between 9 - 10 pm, but resist going to bed.

· Need coffee or stimulants to get going in the morning.

· Crave for salty, fatty, and high protein food such as  meat and cheese.

· Increase symptoms of PMS for women; period are heavy and then stop, or almost stopped on the 4th day, only to start flow again on the 5th or 6th day.

· Pain in the upper back or neck with no apparent reasons .

· Feels better when stress is relieved, such as on a vacation.

· Difficulties  in getting up in the morning

· Lightheaded

Other signs and symptoms include:

· Mild depression

· Food and or inhalant allergies

· Lethargy and lack of energy

· Increased effort to perform daily  tasks

· Decreased ability to handle stress

· Dry and thin skin

· Hypoglycemia

· Low Body Temperature

· Nervousness

· Palpitation

· Unexplained hair loss

· Alternating constipation and diarrhea

· Dyspepsia


If you have many of these signs and symptoms, it is time you consider adrenal fatigue as a possible cause once you have ruled out other organic pathologies. None of the signs or symptoms by itself can definitively diagnose adrenal fatigue. When taken as a group, these signs and symptoms do form a specific syndrome or picture - that is of a person under stress. These signs and symptoms are the end result of acute severe or chronic excessive stress and the inability of the body to reduce such stress. Stress, once a "basket" term used by physicians to explain non-specific symptoms undetectable by conventional blood test, is of no mystery to the body at all.

The ability to handle stress, physical or emotional, is a cornerstone to human survival. Our body has a complete set of stress modulation system in place, and the control center is the adrenal glands. When this gland becomes dysfunctional, our body's ability to handle stress reduces, and symptoms will arise..

Let us now look at how the adrenal glands work.


The adrenal glands are two small glands, each about the size of a large grape. They are situated on top of the kidneys. Their purpose is to help the body to cope with stress and help it to survival. Each adrenal gland has two compartments. The inner or medulla modulate the sympathetic nervous system through secretion and regulation of two hormones called epinephrine and nor epinephrine that are responsible for the fight or flight response. The outer adrenal cortex comprises 80 percent  of the adrenal gland and is responsible for producing over 50 different  types of hormones  in three major classes - glucocorticoids,  mineral corticoids and androgens.

The most important glucocorticoid is cortisol. When this is lowered, the body will be unable to deal with stress.

Mineral corticoids such as aldosterone modulate the delicate balance of minerals in the cell, especially sodium and potassium. It therefore regulates our blood pressure. Stress increases the release of aldosterone, causing sodium retention (leading to water retention and high blood pressure) and loss of potassium and magnesium. Magnesium is involved in over 300 enzymatic reactions in the body. When the body lacks magnesium, it will suffer from a variety of pathological conditions such as cardiac arrhythmias, uterine fibroids and osteoporosis.

The adrenal cortex is also responsible for producing all sex hormones, although in small amounts. One exception is DHEA, a weak androgenic hormone that is made in large amounts in both sexes. DHEA, together with testosterone and estrogen, are made from pregnenolone, which in turn comes from cholesterol.

Pregnenolone also leads to the production of progesterone and as one of the intermediary steps in the making of cortisol. Pregnenolone is therefore one of the  most important intermediate hormones being produced in the hormonal cascade. Prolonged deficiencies in pregnenolone will lead to reduction of both glucocorticosteroids and mineralcorticoids such as cortisol and aldosterone respectively.

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