Removing the Rust-A Seminar for the Seasonal Runner. David Bernhardt, M.D. Department of Pediatrics, Orthopedics and Rehab

Transcription

1 Removing the Rust-A Seminar for the Seasonal Runner David Bernhardt, M.D. Department of Pediatrics, Orthopedics and Rehab

2 Objectives Formulate a plan to start running, improving your fitness Understand the possible intrinsic and extrinsic factors which may contribute to overuse injuries Guide return to activity if you are injured

3 Resources UW Sports Medicine Clinic UW Sports Physical Therapy Clinic Gait analysis Flexibility Core strengthening program

4 Resources

5 Starting point Goals Training plan to reach your goal Flexible

6 Training plan Base starting point depends on fitness level Core strength Core Running by Mark Verstegen Cross train Time to reach your goal

7 Overuse Injuries Common cause of most running injury Stress fracture Tendinitis

8 Stress fracture Tiny cracks in bone march or fatigue fractures Bone fracture which usually results from repetitive overload

9 BONE OVERLOAD Imbalance between bone formation and bone destruction Osteoclasts: bone resorption Osteoblasts: bone matrix formation through production of type 1 collagen, noncollagenous protein and regulatory factors Extracellular matrix Collagen fibers Ground substance Inorganic matrix - Ca and PO 4

10 Mechanical Load Bone Strain Damage > Remodeling Stress Reaction Stress Fracture Complete Fracture

11 Mechanical Load Weight Intrinsic factors skeletal, muscle, joint, biomechanical factors

12 Strain Change in length per unit of length of a bone Repetitive strain usually results in microdamage Imbalance of damage and repair leads to stress continuum

13 Risk of damage Magnitude and rate of introduction of the applied load Absolute number of loading cycles

14 Risk Factors Extrinsic Sport Training Equipment Environment Intrinsic Biomechanical factors Fitness Gender

15 Sprinters high load, short duration Foot: metatarsal, tarsal stress fractures Distance runners cyclic overload Proximal stress fractures: tibial, femur

16 Training Error Insufficient time for remodeling or repair Increase training Increase # of bone remodelling units Porous bone, Increase strain

17 Training error Increase in bone loading cycles (miles) Increased intensity (speed) Sports camps Year-round training HOW MUCH IS TOO MUCH?

18 Equipment Shoes Inserts Attenuate load Kinetic chain

19 Intrinsic Risk Factors Fitness Biomechanical Factors (Cavus vs planus foot) Muscle Gender Diet: eating disorders, low vitamin D

20 Pronation Limited pronation increases the magnitude of impact loading Increases foot flexibility Attenuates ground reaction impact forces Couples with internal rotation of tibia during first half of stance phase

21 Menstrual Hx & Bone Health Extended periods of oligomenorrhea/amenorrhea may have a residual effect on lumbar BMD Drinkwater B et al. JAMA 1990

22 Menstrual history & Diet SF: older at menarche SF: hx of menstrual disturbance SF: higher score on EAT-40 SF: restrictive dieting Bennell KL Clin J Sports Med 1995

23 Risk Factors among Young Female CC Runners N = yo Stress fracture confirmed by radiology test Baseline BMD, body comp Follow-up ave 1.85 y Kelsey JL, Bachrach LK, et al. MSSE 2007: 39:

24 Risk Factor 891 female Marine recruits 6.8% with total of 66 stress fractures Initial 0.86 per 1000 TDE* Subsequent 3.0 per 1000 TDE RF: slowest quartile, secondary amenorrhea *training day exposure Rauh MJ, Macera CA, et al. MSSE 2006

25 Diagnosis Pain localized close to a bone in the lower extremity Focal tenderness

26 Diagnostic tests - xrays Usually negative in first 4 weeks

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28 Diagnostic tests - MRI Sofka CM. Clinics in Sports Medicine 2006

29 Diagnosis Stress reaction: negative xray, positive bone scan with focal tracer uptake Stress fracture: positive xray with periosteal rxn No clear difference in prognosis

30 Diagnosis Stress reaction: negative xray, periosteal edema, marrow edema Stress fracture: negative xray, marrow edema, low signal in the intramedullary bone surrounded by edema

31 Grading I: periosteal edema II: more severe periosteal edema with marrow edema on T2 images only III: moderate to severe edema or periosteum and marrow on T1 and T2 IV: fracture line present Fredericson M et al. Am J Sports Med 1995

32 Prognosis I: 2-3 weeks II: 4-6 weeks III: 6-9 weeks IV: cast for 6 weeks and 6 weeks of non-impact Fredericson M et al. Am J Sports Med 1995

33 Prognosis Fracture line correlates with longer rest time Yao L et al. Acad Radiol 1998 (abstract)

34 Location Tibial (anterior tibial*) Metatarsal Calcaneal Tarsonavicular* Fibular Femoral Femoral neck* Pelvic ischial ramus, ischial tuberosity, sacrum *High-risk stress fxs

35 High risk Risk to progress to complete fracture Tension side femoral neck Anterior cortex, middle 1/3 tibia Tarsal navicular

36 Treatment principles Rest activity modification Equipment Immobilization Weight bearing Nutritional concerns Hormonal concerns Bone stimulator? Non-impact exercise Stairmaster Elliptical Water jogging

37 Treatment Correct malalignment Cross-train Relative rest Follow-up q 4 weeks Allowed to return when non-tender on examination and no pain with easy running

38 Return to activity. PT consult Adaptation 5-10% per week rule

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40 Orthotics? Orthotic influence differs between running and walking Research filled with controversy regarding subject selection, measurement, results, individual foot patterns, kinetic chain Success in reducing pain may be more trial and error

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43 References Bennell K.L., Malcolm S.A., Thomas S.A., et al. The incidence and distribution of stress fractures in competitive track and field athletes: a twelve-month prospective study. Am J Sports Med 1996; 24 : Corris EE. Tarsal navicular stress fractures. Am Fam Physician 2003; 67: Heiderscheit B, Hamill J, Tiberio D. A biomechanical perspective: do foot orthoses work? Br J Sports Med 2001; 35:4-5. Jones MH. Navicular stress fractures. Clin Sports Med 2006; 25: Kudo P, Dainty K et al. Randomized Placebo-Controlled, Double-Blind Clinical Trial Evaluating the Treatment of Plantar Fasciitis with an Extracorporeal Shockwave Therapy (ESWT) Device: A North American Confirmatory Study. J Orthop Research 2006; 24: Placzek R, Deuretzbacher G, et al. Treatment of Chronic Plantar Fasciitiis with Botulinum Toxin A. Clin J Pain 2006; 22: Guten GN. Running Injuries. Saunders Publishing 1997.