Recognition, Rehabilitation and Prevention of Stress Fracture in Runners. Craig Ranson PhD Sports Physiotherapist

Transcription

1 Recognition, Rehabilitation and Prevention of Stress Fracture in Runners Craig Ranson PhD Sports Physiotherapist

2 Stress Fracture in Runners Location Recognition Risk Factors Management Prevention

3 Wolff s Law Bone is a living structure and adapts itself to its surroundings and demands placed on it in accordance to mathematical laws Julius Wolff, 1892

4 Bone remodelling

5 Aetiology Load Accelerated Remodelling Weakening & crack Continued over-load Propagation of micro-cracks Partial or Complete Fracture

6 Staging Acute Bone Stress Stress Reaction Marrow Oedema Periostitis Partial Stress Fracture Partial disruption of the cortex Complete Stress Fracture Full thickness cortical breach

7 Common Locations High Risk Femoral Neck Tibia Navicula Talar Neck Low Risk Sacrum Lateral Malleolus Calcaneus MT 1-4 Base 5th MT

8 History Gradual onset localised pain 2-6 wks after increase in training load Pain at specific stage of session Progressively earlier in training Rest Pain Night Pain Crescendo pain None of the above!

9 Examination Point Tenderness Bony +/- Soft Tissue Swelling Impact pain Run on spot Jump Hop

10 Investigations Xray Bone Scan CT MRI

11 Investigation Algorithm MRI +/- CT

12 Sacral Stress Fracture MRI

13 Inferior Cortex Femoral Neck

14 A process, not an event Workload & Fatigue Muscle Balance Previous Injury Gender Surface Bone Stress Injury Age & Growth Footwear Technique Nutrition

15 Energy, Menstruation and Bone Health Energy deficiency Female Athlete Triad Amenhorrea Sign of insufficient energy for bone formation Energy deficiency reduces bone formation within 5 days

16 Vitamin D and Bone health Calcium regulation Increases intestinal absorption Low Vitamin D results in increased bone catabolism (to maintain serum Calcium)

17 Workload Too Little Lower bone strength Unaccustomed use injury Too Much Overuse injury

18 Management

19 High Risk Aggressive Management Complete Fracture Surgery Incomplete NWB immobilisation Surgery?

20 Pneumatic Boots and Braces

21 Low Risk Conservative Symptomatic Load modification Manage risk factors Asymptomatic Monitoring

22 Stress Fracture Treatment Options Nutrition and Energy Deficit Vitamin D Supplementation LIPUS (Exogen) Medication Nasal Calcitonin Bisphosphonates Stops resorption Old bone stays around

23 Rehabilitation Follow Prevention Principles Cross-Training Milestones Functional/Symptom & Time based (Kaeding 2005, Ivancovic 2006) Team Approach Tackle risk factors

24 Stress Fracture Prevention

25 Previous bone stress injury Prevention plan in place Low threshold for: Reporting Investigating Bone Density DEXA pqct

26 Nutrition & Supplementation Adequate Energy Intake Vitamin D and Calcium Supplementation 800 U Vit D and 2g Calcium daily 20% reduction in stress fractures in army recruits (Lappe, 2008)

27 Allow Time for Bone Adaptation In seven days 4 running/high-impact sessions No more than 2 days in a row

28 Allow Time for Bone Adaptation Progress only one parameter at a time Volume Intensity Surface

29 Surfaces Hardness 1. Grass 2. Dirt Road 3. Track 4. Tarmac & Concrete Hills & Cambers

30 Muscle Imbalance Flexibility Stiff foot and ankle = more stress to tibia, femur, sacrum... Strength, Endurance & Control Smaller weaker calves = increased stress fracture risk muscle has the ability to absorb 100 times the shock than a bone of the same length (Popp 09)

31 Eccentric Soleus Strength Bent Knee Calf Raise

32 Eccentric Soleus Strength Reclining Bent Knee Calf Raise

33 Footwear Appropriate model for foot type & mechanics Rotate at least two pairs Orthotics Socks

34 Technique & Sub-Optimal Loading 1st MT designed to resist bending force Lateralised foot loading (low gear) MT 2-4 stress Unchanged technical issues Recurrence?

35 Technique GRF Foot Mechanics

36 Stimulating Bone Growth High Frequency, Intermittent, Low Intensity, Mulit-directional 5-10 Hz optimal osteogenesis 2 Hz Vibration Plate Skipping Jumping Contacts Rest Period

37 Sample Programme 2 sessions/day 1 skipping 1 multi-directional jump circuit over low hurdles 40 contacts/session 3-5 sessions/week Factor in other impact training

38 Summary Determine Risk of Fracture Type Correction of energy deficit Check Vitamin D Multidisciplinary Rehab and Prevention Plan Creative, appropriate running and conditioning programs Monitoring

39 References 1. Kotha, S.P. and N. Guzelsu, Tensile damage and its effects on cortical bone. Journal of biomechanics, : p Muir, et al., Effect of fatigue loading and associated matrix microdamage on bone blood flow and interstitial fluid flow. Bone : p Bennell, K., et al., Models for the pathogenesis of stress fractures in athletes. British Journal of Sports Medicine, : p Friedl, K.E., R.K. Evans, and D.S. Moran, Stress Fracture and Military Medical Readiness: Bridging Basic and Applied Research. Medicine and Science in Sports and Exercise, 2008: p. S609 - S Ivkovic, A., I. Bojanic, and M. Pecina, Stress fractures of the femoral shaft in athletes: a new treatment algorithm. British Journal of Sports Medicine, : p Kaeding, C.C., et al., Management and Return to Play of Stress Fractures. British Journal of Sports Medicine, : p Myburgh, K., et al., Low bone density is an etiologic factor for stress fractures in athletes. Annals of Internal Medicine, (10): p Nattiv, A., Stress fractures and bone health in track and field athletes. Journal of Science and Medicine in Sport (3): p Nikander, R., et al., Targeted exercises against hip fragility. Osteoporosis International, : p Popp, K.L., et al., Bone Geometry, Strength, and Muscle Size in Runners with a History of Stress Fracture. Medicine and Science in Sports and Exercise, 2009: p Schultz, W., et al., Stress reactions--stress fracture of the upper femoral neck in endurance sports. Sportverletz Sportschaden, (2): p Turner, C.H., Three Rules for Bone Adaptation to Mechanical Stimuli. Bone (5): p Uthgenannt, B.A., et al., Skeletal Self-Repair: Stress Fracture Healing by Rapid Formation and Densification of Woven Bone. Journal of Bone and Mineral Research, (10): p Willis, K.S., N.J. Peterson, and D.E. Larson-Meyer, Should We Be Concerned About the Vitamin D Status of Athletes? International Journal of Sport Nutrition and Exercise Metabolism, ( ).

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