Injuries and RED-S with Dr. Emily Kraus | Koopcast Episode 80

trail and ultra runners what is going on what's happening welcome to another episode of the KoopCast as always i'm your humble host coach Jason Koop and on this episode of the podcast it is all about something that we as runners are really really horrible at it's all about injury prevention and treatment let's face it we're terrible at preventing injuries everybody knows a runner that has been injured few of us know runners that have not been injured and the ones that haven't been injured i actually think that you guys and gals are lying so to cut through all that clutter today and to provide some light on the subject i brought in dr emily kraus who specializes in physical medicine and rehabilitation sports medicine at the stanford children's orthopedic and sports medicine center emily is a fantastic athlete in her own right having competed completed that's what i wanted to say nine marathons including the boston marathon as well as an ultra runner but more important to this discussion is she's also performing a lot of research on ultra runners themselves through the western states 100 and through other means she is an absolute wealth of information i have sent my runners to her and i just cannot say enough about what she is able to do for the community and how

she is able to help runners so i'm going to get right out of the way here's my conversation with dr emily kraus when we're talking offline it's really interesting that we've actually never come into face-to-face or in this in this case in the covet era virtual communication even though we've literally been running around in circles together as well as you have treated a number of my athletes uh when they've gotten injured so that's going to be a topic today we're going to talk about injury and i always feel that this is an area within coaching within athletics and in particular within the endurance realm that we absolutely suck at like coaching is an interdisciplinary profession and i feel like we have a pretty good fix on how to improve athletes we know what the dose response relationship is to different types of workouts and how much mileage you know athletes need to improve and things like that but this injury thing in endurance sports in particular i have no other way to describe it that we just we absolutely fail at this not that we're not trying but we absolutely fail at this every single year every single time there's a study that comes that comes out that tells us what the injury prevalence rate is amongst endurance athletes i look at it and i go okay well let's just say it's half right it depends on what study you look at let's just say it's half the other half are lying i mean

that's the only way that i can encapsulate those studies so to start out with evilly why why why is this the case why is this why are we so bad at this oh i i mean don't be so hard on yourself jason i feel like i'm throwing people like you under the bus because you're like primarily involved in keeping athletes healthy but it's like we're trying but we're just not i can't it's like the weathermen right when the weathermen are off when their forecast is off 70 of the time and i live in colorado springs and the weather forecasting there is notoriously horrible i look at that as the failure of the profession the professionals can't get enough you know of a fix on the situation to give us a good weather prediction this injury thing is the same thing because the prevalent rates the prevalency rates are so high i mean that's true there's nothing that we can change about that running is an injurious sport and i feel most coaches their goal is to is not to injure their athletes i think all coaches that's their goal but i think there is that fine line between getting an athlete to the start line as healthy as possible but also performing at their at his or her best and and that's the kind of challenging crux of the coach is where does that line go and each athlete is individual and that's i mean as much as i appreciate you trying to make the effort to understand the why of these injuries i think it's so complicated and

that's why there's still new research that's getting churned out on the regular and i think we as physicians are continually humbled especially in the sport of ultra ultra marathons and ultra running that we still have so much to learn and understand about that particular sport as to the why and what can we do to reduce overall injury risk as best as possible i think it's hard to prevent just like you said i think the prevalence rates are so high that it's probably going to happen at some point but i think the question is how bad is it and how how soon can that athlete return to their activity without really taking too much time off and i think it depends on the type of injury and some of these other predisposing risk factors and other kind of actions and behaviors that maybe aren't as directly related to the training as far as the workout and the long run and what maybe the coach is prescribing or coaches writing up as far as their training program so it's it's complicated but that's why we're having a conversation to at least understand what we know totally and i i started actually tracking this with my athletes in the mid 2000s probably 2005 2006 because i wanted to understand was i doing better than the average like i wanted to use it as a little bit of a hey coop are you doing a good job with this and so ever since 2005 2006 i've tracked the injury rates with my athletes on

an annual basis how many athletes how many athletes did i have during the year and then how many of them got injured and i'm proud to say that i beat the the averages year after year after year but they're still horrible like they're still they're still absolutely they're still not they're still not very good so we're going to try to get on a pathway to getting better because there's everybody listening to this podcast as an ultra runner and every one of them without fail has been injured and if you haven't call me because i want to know your secret sauce or you're lying um so let's start let's start on the prevention side of things we're going to move through this chronologically we're going to move from prevention to sort of injured this weird transition phase to actually injured and then the rehab part what what does the research tell us and what do we know about the things that can actually be preventative for injury in a endurance we're going to consider this as an endurance running setting so i think the first question is what injury are we talking about are we talking about like a tendinopathy or are we talking about a bone stress injury or stress fracture stress reaction are we talking about a blister i mean all of those are going to take very different strategies and i have a feeling we're thinking more of like the kind of musculoskeletal probably more so bone because those are the ones that the athletes are and the runners are most afraid to to get and as part of their training because of the the concern for the the amount of time that they're out and the the challenge is

it there's a lot of factors that go into play with with an athlete as far as where are they at in their in their training cycle what's their baseline mileage how long have they been running what's their underlying risk kind of profile look like and we're um a lot of the the work that i've been doing in the kind of ultra marathon world specifically is trying to understand specific risk factors for bone health and kind of get a better handle on that and how that's different from a collegiate runner an adolescent runner um are they the are they the same um i my hunch is no um just because the to get to that ultra marathon or ultra running state kind of need to get past some of these other milestones and these other points um to to get to almost that more resilient um kind of stage of training so kind of looking at kind of underlying um risk factors such as um nutrition i think that's a personal interest in um kind of area of research and clinical interest of mine is is an athlete really um kind of just fueling properly and we look at things like um low energy availability and um how that can relate to overall um injury risk specifically bone health and kind of long-term or chronic low energy availability can really lead to disruptions in the hormonal profile of an athlete and can really suppress the release of certain hormones that are important for overall bone health as well as

reproductive function and we're seeing that both in males and females but and i can get into more of the definitions if you'd like me to but i just kind of to give the broad picture right now as far as just overall risk factors um when i think about low energy availability we're talking about either over training under fueling um so not getting enough caloric intake um per day or over a period of days um and then um kind of the combination usually it's a combination of the boat of both of that both of those things and i think it's challenging for an endurance athlete especially because of that um difficulty trying to maintain calories during um heavy training bouts and training cycles i'm trying to figure out what their fueling needs are um when they're doing these big um adventure days especially when we're thinking um at altitude understanding how that's going to affect their metabolism um training um just overall just gut health and how their body is going to be able to digest and absorb those calories so all those factors go into play and especially during a heavier training load um you need to be able to dial that in to avoid that low energy availability over a long period of time because that over time is going to impair the bone health which then leads to that increased risk of that stress fracture in which we can get into more details at the science um if you'd like um so there's that whole piece as far as nutrition kind of contributing to bone health and then there's a whole piece of um genetic risk so what is um just an athlete's overall genetic risk

profile do they have an underlying or family history of osteoporosis do they have other maybe even lesser obvious um risk factors and um that's um one of the topics that we're exploring in um with some of our western states research um which i'd love to share a little bit more about is how does that genetic risk profile um play into an athlete's overall risk and should they adjust eventually adjust their training or not eventually but now adjust their training to make sure that they mitigate that risk and kind of take that into account with the whole big picture so that's something that an athlete should understand maybe that's something that's the conversation that they should have with their coaches like hey i've got an extensive family history of low bone mineral density in my family maybe we should adjust um kind of just overall load and we need to be even more conservative conservative increasing training volume from week to week um or just kind of mixing it up so there's that whole piece and then i think um the thinking about kind of overall bone strength and the the value of um kind of strength training to overall build build bone mineral density and i think that's a hot topic in all of um endurance running like what is the optimal um i think finally we're getting to this point that strength training is valuable for um just both performance and injury risk reduction i think the the research on performance is probably a little bit more robust than the injury risk reduction but anecdotally i prescribe

strength training or recommend strength training not just for an injured athlete but for an uninjured uninjured athlete to keep them from injury and um i think that dosage and kind of prescribing that strength training is very different based on where that athlete's coming from whether they're in the mid-season or whether they're in pre-season and how open they are to strength training um if they're going to be like i personally like my own as a runner i have a hard time going to the gym and lifting weights so you almost need to like find a way to sneak it into the training or make somebody come with me and like i need a training buddy who will hold me accountable for that couple of days a week or else i'm probably if there's some if something's going to give it's going to be the strength training because it's just less for me i just get less joy and excitement from from lifting weights than other people so that's that's the thing that's going to give but i i think that there is some value and there is a lot of great research about um resistance exercise building overall bone mineral density and not just in this kind of um osteoporotic um kind of perimenopausal female um or we kind of think of that very fragile profile i think there's a lot of value even in i'm a young athlete and i'm all about longevity kind of starting i mean we have young athletes doing um doing ultras probably another podcast uh but i think it should it should really start early ideally to kind of get into a good habit and to get the reap the most benefits so i think those are it's kind of the big buckets and then

just overall like micronutrients making sure you're getting um a well-rounded diet getting that calcium getting that vitamin d i think there's um some probably unexplored research and just overall the influence of iron and um the fluctuations of iron and iron deficiency during different bouts of training especially in the running world um which i can kind of get into a little bit but it gets really kind of into the weeds as far as more in that physiology piece so i think an athlete needs to think about all of those pieces and then beyond that just sleep stress level those are also i think an athlete forgets sometimes that like the stress of maybe a new job maybe a pandemic maybe uh a really like some challenges in a relationship that's going to influence overall um just kind of baseline stress level and for me stress is stress whether it's stress from a a workout or stress from a crazy day at work that's going that needs to be factored in and something i've learned as an athlete is to communicate those like all the stresses sometimes um i know coach doesn't want to be um your therapist but being able to be like hey this has been a hell of a week and i am feeling pretty overwhelmed with work and having that coach be able to be like all right we need to like dial back and maybe eliminate that workout or adjust it just the timing of it um to integrate it into the the training program

and those little things kind of i think can help mitigate and kind of keep that training steady and reduce that risk so i mean it's for me it's a holistic approach kind of factoring in in each of these these um risk factors and um possible causes and contributors and it's different for for each athlete as far as you know is this a weekend warrior or is this a kind of dialed i'm going for kind of the big the big races and i'm in that elite kind of pro pro category and and i think there is a lot of overlap in that conversation but i think the focus and emphasis um is a little different too and i think both all all of that all of it's important so i think you you just gave me like seven podcast ideas emily thank you very much it's a lot of workload on my plate now it actually makes it a little bit easier because sometimes content is hard to continue to churn out but the thing that that the listeners can learn the most from that entire monologue from is that injuries are multifactorial there's very rarely unless you fall and you break your collarbone or some some sort of impact injury it's very they are very rarely caused by one singular thing yes there are heavier hitters than others and that's what we try to filter through when we're working with athletes yes it might be more of this and less of that but there's always a constellation of things going on the other thing that that really struck me um as you were as you were speaking is is i was reminded that our theory on why injuries

start to crop up has has kind of gone in waves over the years when i first started coaching it was all about biomechanics biomechanics are the sole cause of injuries and then it moved to footwear everybody went you know minimalist shoes and then they swung over to the maximalist side and and now the theme and i don't know whether this this is probably a little bit of additive you know there's some venn diagram overlap but now there seems to be much more focus on the entire stress load picture and recovery picture as well as nutrition which you just mentioned and i've always found that an interesting facet because like as coaches we've jumped on that like i've jumped on the biomechanics bandwagon and wrongfully so yes there are biomechanical factors at play but it's not like everybody has to have perfect form obviously because everybody would not be injured right we would have solved that problem a long time ago right now right right you know and it's funny i so part of my work i work at emotion analysis sports performance lab and the medical director i'm full just like i'm not a biomechanist i do not spend hours nerding out on um you know is it rear foot strike versus mid foot strike and what what force vectors are at play um but i do enjoy having that conversation and kind of learning from experts and we we chatted earlier we were part of some some happy hour led by a biomechanist with a probably 20 or 30

biomechanics nerds all on a zoom call debating about some of these topics and i think that the big question is so i when i have a runner um usually they're young runners running on a treadmill we're looking at um we're doing like 3d um motion capture i'm looking at their kinetics looking at their kinematics and ensure everybody's going to have some nuanced nuanced differences with their with their form and and i'm not like i don't break them down and say hey your ankles off by two degrees um you're at you're at you're at you're at risk for knee pain for the rest of your life you know you just just hang up the shoes now you just better retire um this is bad news i mean for me it's like it's all there's just there's all these margins of error um kind of within our body and i mean our bodies are resilient to some degree but for me it's like okay let's get them kind of more balanced stronger and we'll get them into a good rehab program but for me it's it's having some of those other discussions as far as expectations and right hey this isn't the end-all be-all like you need to be thinking about your nutrition you need to be thinking about um kind of periodization throughout the year that's a big issue in california too as far as um i call it cox california over training syndrome you just i'm gonna quote you on that that's really good it just it's it happens and it sneaks up on people too they realize you know i've been running

six to eight five six days a week all year round and for me i get i get concerned about just load in that right in those um in those discussions but there are also these other other smaller things that aren't as um transparent and you can't see on their their their training log that that are big contributors or can be big contributors that sometimes an athlete forgets to disclose like oh i changed my diet i went vegan or i'm trying out this other new diet or you know i was trying to you know lose a few pounds and decided to just not fuel as well during during my training or not maybe eat as much um for my recovery because my appetite's already suppressed and that's over time can be really problematic um for just overall injury risk and even just performance too right okay so we have this multi-factorial picture of which we haven't gotten any good answers and not to be a spoiler we're not going to have any lightning bolt answers by the end of this podcast i think both of both you and i can agree on that but we have this multi-factorial picture and runners are they're kind of like nodding their heads and rolling their eyes at the same time yeah i need to rest yeah i need to eat enough yeah i need to control my training load yeah i need to make sure that you know i'm doing this that and the other but the inevitably every runner will come to to this one critical point where they think that they're they think that they're going to have an injury or they get a niggle is usually the vocabulary

that i hear a lot and they're trying to decide whether to train or whether to back off and then how to treat it at the same time this i think is like the ultimate mystery because this is these are the people that go into physical therapy clinics they're like hey can you you know help me fix this and the physical therapist sizes them up and you know gives them some modalities or tools you know neuromuscular retraining and things like that but athletes trying to make this decision process by themselves if they don't have a coach if they don't have a network around them really get confounded by this because they don't know whether to back off or whether to keep going forward so what i want to do next is let's kind of like educate the listeners with what is going on underneath the hood from a physiological standpoint let's talk about a musculoskeletal type of injury what's going on underneath the hood and how can they go through that decision making process of what to do next if these injuries start to creep up and they're trying to decide how to manage them uh oh they're like the niggle you know it's so funny how else would you describe it the first time i i i feel like i use that every now and then kind of clinically or i try to talk to other other physicians about the niggle and they're like like what did you know right you never pass muster under like a clinical standpoint but i don't it's used so and i am a vocabulary stickler ask my coaches i get on them whenever they screw up

vocabulary and i hammer myself whenever i get vocabulary wrong or i just make shit up just to because i can't describe it this is one that i just let fly because i don't have better i don't have i don't have better language to describe it so if anybody has better language please let me know what it is yeah and i think it does it kind of captures this a niggle can be just a little a little tweak a little some some residual soreness from the day before you know i slept wrong it's got a little niggle but it also can be a very early kind of the the red light but like the check engine sign is starting to to flash and it's so early and it's so hard to interpret or distinguish you know is this a nothing or is this something that really requires a change in action i think that's hard for an athlete and especially an athlete who maybe has a history of an injury i think it can be it can drive drive them crazy and i've seen it on both both ends where it's like oh yeah i had this i had the shin pain but i thought it was a nothing and so i just finished my my 20 miler on it and it got really bad at the end and then i'm limping and hobbling off the um home and those there are those moments where first of all i think if if the niggle continues to increase during a training like during a workout or during or if it if it lingers post-workout and to be by the end of the day really is is almost like you don't want to get up you don't want to walk because of a how how much it's really

started to almost get inflamed um and that's i think that's a great um time to say okay let's take a day or two off kind of assess and decide whether this needs to be explored um with a kind of a medical or kind of with the sports medicine team or um maybe it will resolve and i think the the challenge is i mean kind of distinguishing between bone and non-bone or kind of bone and kind of soft tissue the management is is very different right i think it's really hard for an athlete to distinguish is this hip pain that i'm feeling at the front of my hip and most of the time that first first series oh it's my hip flexor it's just a little i just tweaked my hip flexor i i ran up this um hill or like i was i was down running down a really steep um section and i think i just um kind of overdid it or really kind of tweaked my hip flexor um that's fine but if it's really kind of tendon hip flexor there may be some some tightness but there shouldn't be kind of that impact type pain every step and that kind of deeper and oftentimes it's sometimes it's even more deep and kind of harder to to describe and that's where a lot of the bone injuries especially around the pelvis i i start to hear that description you know there's this vague almost sometimes migrating and whether it's um kind of stemming from like the deep like femur the femoral neck um also the sacrum's really hard because that's this like it's my si joint

so i think sometimes these athletes get into injury denial a little bit and start to chalk it up to maybe something that they were told previously when they did have that diagnosis and they're like oh it's just my si joint again um i just need to do this this little stretch or this little kind of hop skip and a dance and then i can go back to to my training and i think the what needs to happen and what what should happen is i think body awareness is is important i think understanding when an athlete may be kind of catastrophizing based on a prior history is important to just be aware and have um kind of a frank conversation of like are you really having severe pain or are you scared because you were so set back by this this prior injury and part of it's valid because i'm a big risk factor for future injuries history of injury or history of that injury and especially with um bone stress injury but i think kind of getting into a bit more of a conversation and for me one or two days of modified activity to kind of further further explore um for an athlete and kind of adjusting training not to the point of sabotaging their their training block but really maybe saving them is is better and i would love to hear your thoughts on this is better than than trying to push through i'm not the coach another disclosure i'm not a coach and i'm definitely more conservative and i'm sure um sometimes coaches get frustrated because i'm like

hey let's dial back and or just kind of take that on the bike i mean or take that to a different mode of activity if they're trying to maintain some aerobic capacity or trying to make sure they don't lose fitness um i think that the the the neurotic side of the athlete really starts to take over and and i think um for me it's it's almost better to for an athlete to to relax realize that you know if you meet with the right person you can try to distinguish whether this is um a couple of days maybe a week of adjustment and really especially with early bone stress injuries or early stress reactions if you catch them early enough and you kind of curb the the training or adjust the training enough oftentimes you can get redirected um an example because i think sometimes examples are nice i had an athlete who had kind of vague thigh pain and she she had a history of bone stress injuries but nothing nothing so um intense or so severe um or kind of higher risk but she she also has a lot of athletes she's an elite athlete and knows nose bone and knows she doesn't want to mess with bone but it was like mid thigh and there's a certain certain maneuver is like getting out of a car where she was really kind of loading the and that really triggered her her pain and she's like i just something's not right she tried to do a

workout on the track she declined and really just dropped off towards the end of the workout um ended up getting um kind of had the hunch got the mri had a low grade stress reaction low grade bone stress injury of the femoral shaft um she was able i worked really closely with her physical therapist talked about kind of load management and what the next four weeks will look like um as soon as um we felt it was safe we got her on the bike doing workouts on the bike um i think people forget how awful a bike workout can be it's almost more torturous than a than a lot of um running workouts and and she was able to get back in a really i mean like a four to six week time frame and i mean i don't want to give that as an example that oh okay all i hear was four to six weeks that's what i'm taking away from this but no it's the we caught it early enough and we were able to really get that athlete back safely to that elite level and she probably wasn't doing higher like higher level workouts for quite a bit a little bit longer but you know femoral shaft stress reaction is way different than a fracture like if you wait and you train and you get to the point where that literally breaking point you're either out for the season or you got a rod in your in your in your corner and and and those are the the things that the athlete needs to listen to is that you know we got to adjust the bone remodeling during that that time and sometimes it's just taking the dial back that's

enough to allow that remodeling and um kind of that reset to happen you you asked me this and i'll answer it um the way that i look at this through a coach is through a directional lens because i realize that athletes are always going to have pains and things like that just through the course of training it's a hard freaking sport you know running and trail running and ultra running it's a hard freaking sport you're asking you're intentionally damaging your body in order to get better that's the that's the fundamental proposition with with physical and endurance training um but i use a directional arrow is i see a trend line that's getting worse that's when i'll start to put in advanced interventions go see your physical therapist we're going to you know back off the training load we're going to do x y or z whatever the the thing warrants if the trend line is the same or it's getting better then i kind of kind of i realize that that painful sensations i was choosing my words very carefully there that painful sensations are part of the occupation it's part of the gig it's part of the game you're not going to be able to avoid those all the time and then sometimes it's what you want in order to overload the body so i've always used that kind of rule that directional rule of thumb where if i see things trending in the wrong way for two or three days that's that that's kind of that's my that's my litmus test not one day not one day that were the pains you know just a little bit two or three days where it's gradually getting worse because i i've always gone back to this fundamental proposition

that were predominantly dealing with overuse injuries and i'm emphasizing that intentionally they don't happen because typically don't happen because i took a wrong step over here or i did this hill workout or whatever that is just the end point in reality that overuse injury has been brewing for weeks or sometimes months and if you have a good dialogue and if the athlete has good body awareness to use your vocabulary m if they have if they have good body awareness they likely have noticed that or should have noticed that weeks ago and didn't pay attention to those directional arrows that that's fundamentally that's the way i've always tried i've always tried to manage it i don't play physical therapist and okay go you know do e-stem or contrast baths or anything like that i call them the experts when it's when it's time for that but as somebody who monitors training on a day-to-day basis that's kind of my fundamental my fundamental role as a coach i've just found that that directional arrow can you get you get more good answers out of that and you don't have to curl the curtail the training unnecessarily the linchpin and all that is is the athlete has to constantly be updating the subjective feedback within their training log because it's so important sounds like that was like a nice nice plug for your ass i don't know it's taken me a while to do that but like i said i still think i suck out i think everybody sucks at it um it's it's hard i mean

it is it is hard this transition between not being injured and having some like something to deal with something that you're aware of and getting injured if we had a perfect crystal ball we'd never even get to the first step right but the reality is is that we don't is that we don't a lot of what what you've been doing recently is research to try to illuminate what is going on underneath the hood specifically within an ultra running population and so i want to give you a little bit of the floor this podcast is going to come out before western states so hopefully you can recruit the entire 400 some odd person field into this study do you guys let me let me pause for a second get on soapbox for just a minute or so here the western states endurance run does a phenomenal job of supporting research and i had to look this up the other day because i'm in the middle of writing the second edition of the book and that's not a shameless plug it's just background story when i when i first started coaching the year that i first started coaching ultra runners throughout that entire year exactly six papers were published that had some version of ultra running in the title i had to go back do a retroactive pub med search to find this ultra running ultra marathon whatever it was exactly six during the year that's not a lot now there's research that existed before that but 15 years ago it was really skinny and it was very very very hard to drive research and science based practice when none actually exists western states has

been at the forefront of changing that they're not the only player there's a lot of other players in there but they actively support it to the nth degree they pull money out of their budget to support it i just think it's awesome emily you're involved in that so thank you anybody who gets the opportunity to participate in one of these research projects that's done through a race through their local university do it take advantage of it it helps everybody it feels good to do afterwards maybe the study is a little invasive and it doesn't feel good during but afterwards when you look back on the experience you'll actually feel that you've contributed to something and we're at the stage where all these contributions are incredibly important and they add they add just a tremendous amount to our knowledge to it that's my soapbox go and join emily study what so what's going to come on tap what have you been doing with western states and what's going to kind of come come next jason thank you for that plug um we are yeah we'll be sending out a recruitment email email probably early may and that's really helpful and i think um so important too to just get a diverse population and just any information is going to contribute to um the the science and the understanding of um ultra ultra running but so this is our our third year um we've been lucky to be able to conduct research at western states um in 2018 and 2019 and it's really been a continuation of um this this idea and this um hypothesis so you'll um see or you'll notice that

we don't have a lot of um publications out yet because we're trying to we're a little underpowered we don't have enough um athletes to really make um broad conclusions it's hard yeah i'm going to like put that little asterisk like hey um we're still some of the some of the stuff that i'll talk about um we still need a bit more information to make sure that it like holds up but um our studies um so there are primary analysis we're trying to look at different risk factors and i'll kind of get into some definitions with female and male athlete triad um so those triad risk factors um in ultra marathon runners and how it really relates to to bone health and we're also looking at um specifically that association with stress fracture risk um bone mineral density risk and um the relationship with different um genetic risk scores and so that's um all kind of things that we can get at this race site or at the at um squaw the days before we're gonna call it olympic valley now somebody's gonna come up after us after this podcast is over since they officially changed the name to olympic valley thank you olympic valley i'm helping you out on that one emily you know what's going to come down the pipeline if we let that stand yes yes i appreciate i appreciate that correction uh yeah olympic valley and um we're going to be on um on site so um we have um funding we've secured funding from western states research foundation um it's been wonderful working with them they've been super supportive

each year they review different um research proposals so um they don't play favorites um we we pitch our um our proposal and kind of what our our funding needs are each year and and this year actually last year we got funded um and just um because the the race was postponed or canceled um we we were able to push it to um 2021 and so we have um partnerships with inside tracker we actually get um blood draws fasting blood draws shockingly enough we get um runners to get um usually early in the morning they'll come over and get lab lab draws at a site um on um really really near actually registration and then we also get um bone mineral density testing through um dexa scans type of um kind of the method i guess the gold standard i'm using air quotes right now to to measure bone health um there are limitations and with with um dexa scanning um but it's kind of our own kind of true the only true measure that's easily accessible through the clinical setting so we use that to um just get a better understanding of an athlete's um bone mineral density and then we also give each athlete an extensive pre-race questionnaire that they fill out online and try to get more information about um kind of where they are as as a runner like what's their their training level how um how competitive do they interpret their their training to be um what is their um kind of injury history um we can't actually we don't follow these athletes in the future so

prospectively but we do try to get as much information as on prior injuries including bone injuries um genetic history as far as kind of any family history and then we also ask about um for females on menstrual history and in males we do ask some other kind of kind of sex related questions about um kind of libido and morning erections which can be influenced by hormonal suppression um through the low energy availability kind of going back to that piece and then we gather all that information and we also look at their um kind of finishing like how many of those athletes who got all that information actually finished the race um we do a little bit with um performance but really it's more just trying to get this um this risk um profile so i want to kind of share some of the information we are trying we are um pub we've submitted a manuscript it's under review hopefully um we submitted our revisions and within the last month so hopefully gets accepted um i was i'm submitted to a journal and a reputable journal and it would be great to be able to get that out hopefully before the race um but some of the findings were um one and i just don't want to misquote myself so i love the fact that you have to look up your own quote in the research paper to get it right i get paranoid when i'm quoting other people but the fact that it's you that makes me feel a lot better well lots of statistics and numbers and i i'm really hard i mean it just it's hard for me to keep those numbers in my head but um 37.5 percent of women reported a history of bone stress injury that's higher than

some of the other um prevalent studies that are out there in ultra marathon runners i think um those are around like 20 21 in females so higher bone stress injury or stress fracture um rate um and then in males it was about 25 20.5 dudes are lying this is i don't buy that for a second the guys are lying there's no way that's only 25 yeah yeah um and then the overall of bone mineral density it was interesting um males had low a greater percentage of lower um bone mineral density z scores so we kind of that's how we score um we look at the lumbar spine that's kind of our best indicator of kind of bone health that has kind of a mix of trabecular and cortical bone or different types of bone and um um the 30 percent 30 of men had bone mineral density um z scores of less than negative one which so the other challenge with bone density and measuring bone mineral density with these um dexa scans is the scoring system is based on um healthy age match controls so people out in the community that may not be engaging in weight-bearing sport so you would think that a runner especially an ultra runner who is putting a lot of load into their bone every day should have overall higher bone mineral density so if you look at kind of what is like as a what is osteoporotic um definition um in a general

population that is different than what we kind of through american college of sports medicine um guidelines for what low bone mineral density is in our in our mind and so we use less than negative one as our cutoff and so 30 percent of males had bone mineral density z scores less than negative one however in females only um 16.7 so almost just almost 17 percent have had scores less than negative one and so for for me it's like what what is going on with this this male ultra running population that kind of is is higher as far as higher risk um based on based on z score and just overall under kind of lower bone stress injury history that's right they're lying i'm telling you emily this i've got the answer for your research right here they're lying if the the the mech if the mechanism if part of if a big part of the mechanism is poor bone health and the guys showing up to the line have markedly poorer bone health than the women they they should have more bony stress injuries coming into the race so the fact that the in that the research or the survey is saying is saying the inverse is true they're just like flat out i'm telling you right now at case close they're just lying yeah and i mean maybe like i'll give the give the guys the benefit and maybe they are they forgot about injuries in their past maybe they're maybe they were minimized

like oh that really wasn't an injury yeah it really wasn't an injury oh god sorry this is i'm just calling it like it is but the other interesting thing is some of these like genetic risk scores and so we found that the genetics so we looked specifically within the genetic risk profile at different um snips and single nuclear poly polymorphisms make sure i yeah yeah um the snips and we looked at uh snips that helped that work previously correlated with um bone mineral density and low bone mineral density and bone mineral density risk and we found that that bone mineral density genetic risk score was correlated with bone mineral density in the male so the low bone mineral density low bone mineral density genetic risk was consistently was consistent with the bone mineral density that we found in in DEXA in males. However, in females, we did not see that. And I will say that we're underpowered.

So maybe there would be that finding. But for me, it kind of takes us back to that conversation at the beginning about this multifactorial nature for bone health, bone mineral density, and bone stress injury risk. And are there more hormonal influences if you kind of had to put a percentage in a weight, in a weighted pool as far as how much weight do we need to put on the hormonal risk profile versus the genetic risk versus the biomechanics versus the load? And is that different in males and females? And is that different in the ultra running population in particular? And my, unfortunately, my answer is we still don't know. But that's why you do the research. That's why you do the research when you don't know answers.

And that's why it's important. I mean, I can remember, you know, part of, once again, trying to encourage people to go do the research. It wasn't that long ago where we used a scale at an aid station to determine hydration status. In Western states in particular, they would pull you from the race or make you stay in the aid station if your body weight had dropped below, I think it was 8% of your starting body weight. And we know largely through research that was done at Western states that athletes should actually be losing weight during the course of the race. So this policy had the opposite effect that it was intended to where athletes were intentionally trying to overhydrate, which causes other problems, blah, blah, blah. But my point with that is, is we didn't know that before the research. Now we know it, we can reverse course on that particular policy, which was bad for athletes. Let's get that right. That was not a good policy for athletes to have. And a lot of other races had it not to throw Western states under the bus or anything like that. Um, but it doesn't happen unless people actually do people like yourself, Emily actually do the work. So everybody let's shoot for 400. How many people are in the Western states field this year? 460 something for hunt. Let's shoot for 400 people that are involved in study. Let's just get everybody, especially the women, because as you mentioned, they're underrepresented and ultra running to start out with. And they're underpowered in the study that the studies that you're involved in. Um, okay. So what, what's net, what's next? What do you want to see kind of come down the pipeline

three or four years from now in this whole area of bone health and injury prevention, like your wheelhouse, what do you ultimately kind of want to want to see happen in the field? Oh, wow. That's, do you want to know my dream? Yeah, totally. Because we can make it happen. We can make it happen. How long is this podcast? Um, so I think, so here's, here's my dream. Um, one is to have better translation of the science to the people that need to hear it the most. Yes. Yes. So I think number one, we can do all the research in the world and do like find all these novel, really interesting findings. But if that's not going to change the behavior of an athlete, the behavior of the coach, the parent, I work with a lot of young athletes and change sometimes the culture. And that's like a big, a big ask, but I think we need to change oftentimes change the culture within the sport. And, um, I think that starts with good science, both kind of the like deep down kind of technical science where you're like in the lab, but also like out in the world and like, what's going to motivate people and kind of look at more behavioral changes and what's, um, kind of into that psychological component of all this, get into the psyche. For me, I think that's like a big, um, a big number one, big goal is to be able to find a good way to translate this

information in a very like data heavy kind of always coming at you type of world where it's hard to distinguish the, the good information from the, maybe not bad information, but not the information is there, but it's not maybe presented in the right way and delivered in the right way. And it can really confuse an athlete, even a coach who's just trying to keep up and keep their head above water. And so I think, um, kind of my call to action is we, as, as physicians and researchers, we, um, it's, it's part of our job is to, is to educate and not just even in the one-on-one. I think that's an opportunity in the one-on-one clinical setting, but as far as the big impact, I think we need to find ways to disseminate that information better. Let's talk about a way that we have done that. Cause I, I think that this is a good bridge to the last topic I want to talk to you about.

I think a really good way that we've done that recently, maybe in the past four or five years is this transition of describing a certain phenomenon in endurance sports from the female athlete triad to red S or we call it red S in this podcast or reds. I, you know, I, I've, I hear it both ways. I talk to, I talk to like red S researchers and she says red, I say red S and we like, she's not correcting me. I'm not, I'm definitely not correcting her. We'll go with red S. That's the way I said it in the audio book for the last four days. Since that's what I've been recording. We'll go with red S. Okay. But that, that is, I think that that is a brilliant illustration of, we used to describe this issue this way. We realized that there's more nuance to it and we can describe it better in an effort to educate athletes and practitioners. Now we're going to call it this. Everybody got on board with it. This is what I thought was really phenomenal. Phenomenal with this whole transition is everybody was like, yes, this did, we needed to make this transition. We're going to be on board with it. We can call it reds or red S. I don't care. We're just happy. We made the transition. That is what is supposed to happen.

When we recognize a failure of what we are doing as a community, we can all collaboratively come together and say, okay, we're going to transition to this. This is the new model. Here's our framework. Here's how we're going to discuss it. And the reason that's, that it's important, which you just touched on is that when we are all, we coaches, scientists, athletes, practitioners, physical therapists, people in the medical setting, orthopedic setting, when we're all operating from the same playbook, there's an intraoperability between all of those groups where we can then leverage all of our strengths, but it doesn't happen unless, or it doesn't happen to the same degree. At least if we're not using the same vocabulary and we're not using the same playbook, that's why this transition is interesting. But let's get down to the practical pieces for the athletes. Cause I know you've done a lot of work in this area first, starting out with the female athlete triad.

What was that? What were the failure points and why are we moving to this new model and what's important for athletes in this, I'm calling it a new model, but it essentially is what's important for athletes in this red S model. Yeah. Oh man. I mean, I think this, this is a really good example of yeah, that, that translation and where are like, where are we really going and what is our underlying goal? And I think the underlying goal is very similar as far as kind of what we're the point that we're trying, the message that we're trying to get across and to kind of like get started. So the female athlete triad kind of really stems back from like the 1980s. Dr. Barbara Drinkwater had some like really seminal research that identified that this low energy availability has an important piece to, to both kind of hormonal balance and ultimately bone health.

So I think we kind of need to remember that like low energy availability is this cornerstone for, for both kind of female athlete triad and eventually red S. So in the American College of Sports Medicine defined female athlete triad as three interrelated components, low energy availability with or without an eating disorder. So it doesn't have to go to the extreme of an eating disorder, but I think there are disordered eating tendencies. And I can give you some stats even from this, this Western state study that over almost half of the males had disordered eating behaviors. And I think two thirds of females around that had disordered eating behaviors. Now that's not an eating disorder. And I think that there can be more in that healthier norm of disordered eating.

That's not really what I meant to say. There can be periods of different low energy availability cycles within a training that can be done safely, but oftentimes, especially if done in isolation, it can lead to under fueling for a prolonged period of time. And so this goes to our second piece, which can lead to in females, irregular periods or what we call menstrual dysfunction. This could be a delay in the first period. So this is an athlete, a young female athlete who maybe gets her period at 15, 16 or later, or it can be an athlete who during heavier bouts of training loses her period or has not, doesn't, doesn't even have to lose her period. That cycle can change.

It can get lighter. It can maybe change as far as kind of shorter duration or bigger challenge is they may just not ovulate, but they have periods or they may have changes in other hormonal profiles, but still have periods, but things are starting to get off kilter. So that reproductive suppression through irregular periods can then lead to changes in bone remodeling, which is the third, which is low bone mineral density or impaired bone health. So that might be a history of stress fractures. If we don't, we don't measure bone mineral density, we don't have to in all athletes, or can actually be low bone mineral density as we defined earlier through American College of Sports Medicine at the ADEXA Z score of less than negative one. So those are the three components. So the female athlete triad, kind of, there's a lot of research on the relationship of triad risk factors and low bone mineral density triad risk factors and prospective or future stress fracture. So we were able to use that triad risks tool to actually, as a predictive model, to actually predict potential risk for future stress fracture. And that could help stratify risk for a physician who's trying to communicate with an athlete how to maybe adjust training or in a collegiate setting, they may be restricted from actually participating in sport to some degree. So as research evolves, a similar phenomenon was seen in male athletes. And so this research group, this female athlete

triad coalition coined that term that a male athlete triad. And the main difference being, instead of irregular periods, males presented with hypogonadotropic hypogonadism. You know, you use that and say it 10 times fast. You did that really well. I was wondering how you were going to, how that was going to roll off the tongue. Kudos to you. I would have, I would have stumbled over that a hundred times. What is that, by the way, listeners are now just rolled their eyes going, and I have no idea. That's too many syllables for me to keep track of. So that is a suppression, again, a suppression of sex hormones that are more specific to a male, a male athlete. Specifically, the most common hormone that we talk about is testosterone. The challenge with measuring testosterone is there's a wide array of normal, more air quotes over here.

And the lower testosterone, we do see that in endurance athletes. And that can, again, lead to other reproductive effects and suppressed bone mineral density. So similar type of phenomena, but a little different in males. But we're still seeing using, we, in our collegiate athlete population, also part of another research study called the Healthy Runner Project. It's been going on for seven or eight years now with Stanford and UCLA. And we found that this cumulative risk assessment tool, looking at the male male athlete, is also predictive of future bone stress injury risk. So there's something, something happening here. So in 2014, the International Olympic Committee came together and saw these, saw low energy availability as this cornerstone, and really wanted to expand this definition or kind of take this, expand the triad to encompass more health and performance consequences. And so they coined the term relative energy deficiency in sport to really capture that. And that includes male and female athletes. So I think one thing that one misconception is that RED-S is really replacing, as far as terms, replacing the male or female athlete triad. And really, the understanding is that the RED-S is an expansion of this female and male athlete triad. So if you actually

look at, I know, Jason, you'll probably show this graphic or figure, the both health and performance and the other side of this, you'll probably show this. And so I think that is really important to think about the overall kind of the overall kind of mood and the mental health pieces. And I think you can see that there are all these other circles as cardiovascular effects, affecting the immune system, affecting just overall kind of mood and the mental health pieces. And I think those are really important factors that can be a consequence of low energy availability that just have yet to be fully understood and studied to the degree that the triad has been studied. So I would say, I mean, we kind of think about the timeline of the female triad and then the male athlete triad. And that started in the 80s and 90s. And RED-S is really kind of getting going in 2014. And thanks to the International Olympic Committee has really just churned out some great research. There's still a lot of work to be done. And I think between both groups, the triad research group and the RED-S research group, that they're both moving forward. I think just like any, I think this is very common in academic medicine and in research where there are some clashes as far as ideas and theories. And I think that's, I mean, it's just like healthy competition in all realms that that's going to hold each to a high standard.

And I think one of my goals with some of this information and dissemination of information is I hope to have a platform that I can really pull in both of those concepts and kind of explain the relationship and the good research that's coming out of both of those ideas. And I think ultimately, the vision is to help an athlete understand when they're maybe presenting with early signs of something like RED-S or the triad, and then be able to almost communicate that, be like, you know, you know, coach, I think I am dealing with some issues related to low energy availability. I need to kind of reassess and look at maybe my training or maybe just like fueling timing and make those adjustments earlier and hopefully salvage the season, make both coach and athlete happier because a running and training athlete is a happy athlete.

100%. So you mentioned you want to educate people on what some of the early signs are. What are you finding out so far? Like what are some of these things that the athlete should watch out for where they need to put a pause and say, okay, I need to assess this. And then we can take it to, it'd be really easy to just say, listen, you need to increase your energy intake. But what's the, like functionally, what's the outcome? How should the athlete course correct if they do see any of those signs? Yeah. I think that like the easy, the low hanging fruit, the one that's been studied the most is kind of an athlete or female athlete losing her period. I mean, that's the one we talk about the most. And for me, that's kind of late in the game. That the findings show that like low energy availability, low energy availability can really lead to those hormonal effects that don't lead to that delay in period or that suppression. And I mean, that can happen within a week or two and really start to affect some of the bone remodeling and some of those, um, those serologic markers or those, um, bone biomarkers. So for me, that's, that's too late. And I think it also is challenging because a lot of athletes are on different types of hormonal replacement therapies, which is another topic that we could, we could really get into as far as some of the challenges one and understand and kind of teasing out, um, and athletes like true, um, kind of internal hormonal profile when they are, um, on some type of hormonal replacement. But, but hold on, this, this shouldn't get glossed over.

If athletes are in this state, you're saying stop, full stop the train. Like that's too late. You need to completely reassess what's, what's going on because it is such a lagging indicator or it lags so long. Okay. I want everybody to, to pay attention to that. Cause that's super important. Let's try to back up though. We're, we're, if there are leading indicators, what could they be? Or what are some of the earlier, at least don't lag as much, some of the earlier indicators that issues might start, uh, uh, come, come, come about because of red S. Yeah, I think, um, this is where it gets gray, just like full disclosure, because, um, we are still trying to understand, um, what I think it's, it's hard because there's a lot of overlap and one, um, the chronic fatigue. I think I see that an athlete maybe is underperforming or consistently underperforming.

And that can also be a part of a training cycle too. So it's like, how do you know when, um, and I think it overlaps with kind of overtraining syndrome, which is really hard. And this diagnosis of exclusion is are they overreaching or are they in this early red S phase? And I mean, the true question, Jason is what's the difference? Like are, is that early red S if addressed really quickly, kind of part of sometimes that, that, that training cycle. And I think what an athlete needs to understand is kind of consistent kind of underperforming as far as, um, just, and, and feel and, and poor, poor sleep and irritability and all these other factors that can be from a number of different reasons, but can also be from just consistently that low energy availability piece.

Sometimes there's a kind of obvious, um, kind of looking back at their training, if there is an acute change in our acute increase, like sometimes I see it in those transitions, when an athlete goes from, um, middle school to high school, high school to college, college to, um, kind of out in there on their own, maybe adjusting or kind of going to that next race distance, they start to fall into, um, uh, a low energy availability state. Um, you can start to look if there are some changes and, um, just overall kind of cardiovascular profile. So this is something that I'm really interested in to see if, you know, will heart rate variability be a potential future indicator of, um, that low energy availability state. I think it's hard again, to tease out whether that like over-trained and kind of maybe too much strain is, is also at play.

I want everybody to listen to Emily's vocabulary. Will it be not, is it currently? Because if you survey the landscape right now, you can definitely get the impression that that, you know, ship has left the dock that we've already determined that heart rate variability can give us these indicators on X, Y, or Z. And it is very much not the case. Yeah. I mean, I think we're still like, we ought to be honest and humble with what, with where we are in the science and the interpretation of the science. And I think it's really easy, especially when there's, um, something fancy and like something new out there that, that could be a quick fix and a quick answer and, um, has the right algorithm could be, um, interpreted that way. And I will say that like something like heart rate variability could be a, um, could be a very useful, but I also can see it being, um, very distracting.

Yeah. And, and I think it's, it's all about thinking about all these other factors. So I know, I know I'm not giving you a very clean answer as far as some of those early signs. And I think it's because we really don't know enough to, to be able to, to, to share with an athlete, some of those early signs without maybe getting some of those, some of those blood markers, for example, um, some of the thyroid, um, function, like three T four, um, total T three that you can start to see those getting suppressed earlier on. But I think expecting an athlete or like understanding how to interpret those lab results is really, really challenging. Um, kind of in the, in a practical setting. Yeah. That's one of the big issues I've always had with, uh, a lot of the blood biomarker companies that are out there, the direct to consumer ones is that you either have to be doing the testing on such a frequent basis and then creating an individual profile for the people in the, the frequent listeners, this podcast, or remember the podcast I did with Sean Arnett, we talked about this a lot. The frequency has to be such almost on a weekly or biweekly basis. It has to be so consistent that you can build an individual profile for an athlete in order to use some of those biomarkers biomarkers as some of the initial indicators of whatever you're looking at, low energy availability, over-training, over fatigue, kind of whatever it is. If you're not taking those blood samples that frequently you get a lot of false positives and false negatives, and you, you almost are looking at

a disease state at that point. And then course correcting for a disease state versus an optimization state. So that's another 10 podcasts that you just gave me, Emily. Thank you for that. Any time. But I think the, the drive home point for the listeners is that energy availability or lack thereof is at the center of all of these cascades of all of the, this cascade of negative consequences. The negative consequences were starting to flush out how much like cause and effect there actually is. And it's different for different people, but energy availability is at the center of it. How do you get there? Well, the simple answer, or how do you not get there? The simple answer is, is make sure that you're in an, you're not in an energy depleted state. That is way easier said than actually done, particularly with the training loads that, uh, that ultra marathoners have to regularly encounter throughout their training. A simple way though, is not to deploy any strategies that intentionally do that. Right. And we see this a lot, particularly in the ultra marathon and Ironman triathlete, uh, triathletes see this as well, where there's just been this recent rash of athletes that are athletes and coaches that are trying to leverage intentionally leverage low energy states to produce a metabolic adaptation. They want enhanced fat oxidation and things like that.

And I think the thing to keep in mind is, is that always comes at a cost. And many times that cost far outweighs the very small benefit that you could get. And you could even argue that there's no benefit at all. No, I think you, it's such a good point. And I really enjoyed your podcast interview with Craig Sale. Shout out to what Craig is doing and, and Kirstie is, Kirstie's doing out there on just better understanding, um, those fluctuations in fueling. Um, Trent Stellingworth is also another big researcher in like in that world. And I was just reading some of the research specifically in that ultra endurance population and, um, like fueling and fueling strategies. And I think there's always this dream that we're going to try to like kind of cheat the system and figure out how to like find that sweet ratio. I mean, do we really need carbs? Oh, maybe not. And then ultimately I just, I love some of this research. Um, Louise Burke just put out that really kind of refuted and like all, like not all, but just hit was like, Hey, like pump the brakes here. Carbs are really important for multiple different reasons, especially in an ultra endurance world. And so I, I think that you just highlight a really important point that fuel, um, there are certain kind of specifics that we need to think about as far as the type of fuel that's putting into our body. But I think everyone can

agree that that fueling is incredibly important and, and the timing of that, especially in, in an ultra marathon runner, you need to have that dialed. You need to practice. You need to find ways. Like if you struggle to get fuel in your body at like three hours, four hours into a race, then you need to practice that and figure out how, how to get that fuel in your body, because ultimately that's going to affect your performance. It's going to like wreck havoc on just multiple different systems, including bone health, but we're, we're understanding all the other effects that that may have that we're, that we don't fully understand, especially in the ultra endurance population. And I think another like piece is the whole idea of supplementation and thinking that you can just supplement with all of these different micronutrients and kind of, that's just going to be this panacea that allows you to be resilient and unbreakable. But I think that there are, there is a time and a place. And I, I prescribe supplements quite a bit, especially if an athlete who has an injury to just make sure everything is optimized, but, but really thinking about ways to get that from the diet. And if there, if it's consistently low kind of asking the big, why, um, that like some of the other factors that could be, could be at play too, because long-term micronutrient deficiencies are going to, going to be a problem and could lead to an injury or could also lead to other kind of health effects as

far as kind of prolonged fatigue and other, other factors. A hundred percent take home messages is eat your Wheaties people. Eat your Wheaties. Emily, we're going to let you go. Um, I promise I'm going to put the links to everything in the show notes. So if you're at all interested in Emily's research or any of the research that's coming up at, uh, out at Western States, go ahead and view the show notes. Also have links to your social media account. You're a good Instagram follow, by the way, go follow Emily on Instagram. She puts out really great content. It's informative for me as a coach. It helps me keep track of what's going on just by following people like you, Emily. What, uh, what else, how else can athletes interact with you or interact with the research that you're involved with?

Yeah. So I, um, yeah, I've got the, got the, like the Twitter and the, like the Instagram, um, to kind of try and push information. I will say, what's the handle? Um, so Emily Kraus MD is the Twitter handle. Um, K R A U S is my, how do you spell my last name? And then I have, I have two Instagram accounts, which if I, if I needed anything else to do adding another Instagram account, let's just throw it on the, throw it on the list. Um, so there's Emily Kraus MD, which is a little more social, um, more kind of family and like fun. And then I try and do it. Um, Emily Kraus MD underscore sport science, where I try to push, and then I'm trying to be better about pushing some good, um, information to kind of the followers and what I'm interested in and some of the research that, that I'm doing. So, um, those are kind of the social media. And then I do have a website that if you are interested in trying to get in touch with me, um, both for like a clinical with clinical questions, um, there are ways, um, often to do kind of telehealth visits, um, out of state, it gets a little bit more challenging, but we, um, I'll kind of do my best to help an athlete in whatever way I can. And that's, um, Emily Kraus MD.com.

Just Google Emily Kraus. You'll find it. Emily, on behalf of the listeners. And for me personally, thank you for what you do. You've helped me as a professional throughout the course of your career, whether you realize it or not, but also you've individually helped a lot of my athletes, uh, with various issues as they've gone through their, their running career. So I owe you a debt of gratitude for that. You will continue since we all suck at preventing injuries. We've already been through that. That's going to continue. So I appreciate the fact that we have individuals like yourself that we can continually lean on. Thank you, Jason, for this opportunity. Thanks for having this podcast to kind of give a lot of these, um, researchers and clinicians and scientists a voice to be able to kind of get to your listeners. Cause that's, I mean, that's why we're here and it's super rewarding. So thanks for the opportunity. A hundred percent.

All right, runners. There you have it. There you go. Much thanks to Emily for coming on the podcast today. We will have to bring her back on when we have a little bit more information as to what actually turned out from all these studies that we are doing at Western States. I cannot emphasize enough. If you have the opportunity to participate in research, please go do so. It helps our understanding of the sport or injuries in this case, or bone health in this case, a tremendous amount. And none of that is possible if we don't get people to volunteer for the studies. So go out there, volunteer for the studies. You will thank yourself later. And I thank you in advance. I also thank everybody for listening to this podcast. If you have not had the opportunity, go on over to Apple podcast and give this podcast a rating or review. It means a lot to me and helps out the podcast a tremendous amount. All right, that's it for today, folks. And as always, we will see you out on the trails.

We'll see you in the video. We'll see you in the video. We'll see you in the video. We'll see you in the video. We'll see you in the video.