Annual stress fracture incidence. Keep them Running. Men 9.7% Common Injuries. Women 31.1% Preventive strategies. Female Athlete Triad

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1 Indiana High School Track and Cross Country Coaches Association Stephen M. Simons, M. D. FACSM Director of Sports Medicine Saint Joseph Regional Medical Center, South Bend, IN Team Physician United States Olympic Team Athens, Greece 2004 Keep them Running Preventive strategies Female Athlete Triad Shoes Nutrition Directions Preventive strategies Female Athlete Triad Shoes Nutrition Tendinitis Achilles Patella Posterior tib / peroneal ITB Patellofemoral pain syndrome Fatigue fractures - results when normal bone is subjected to repetitive loads, none of which can individually cause fracture. Stress fractures Insufficiency fractures result when normal stresses are applied to abnormal bone. These are underling conditions which weaken bone ie, osteoporosis, Pagets disease, hyperparathyroidism, rheumatoid arthritis, osteomalacia, osteogenesis imperfecta, rickets, and irradiation. Time to Stress Fracture Increased stresses applied to bone lead to increased osteoclastic resorption which peaks at about 3 weeks. The military reduced stress fracture incidence by reducing the weight bearing training of new recruits in the third week of training. Annual stress fracture incidence Men 9.7% Women 31.1% Incidence by Sport Running contributes to more stress fractures than all other sports combined. Track and Field Ball sports: basketball, soccer, football, baseball, volleyball Stress fracture recurrence rates T&F recurrence rate is 12.6% Military recruits sustaining a second stress fracture at different site than stress fracture site during basic training 10.6% Incidence by gender and race: Brudvig reports an overall relative risk for females 3.5 x higher than males. White males: black males relative risk 4.7 White females: black females relative risk 8.5 Race related incidence differences are based on military studies. Incidence gender difference: Military studies: Female to male x. A gender difference is not so evident in athletic populations. This relative difference is 1-3 times more stress fractures in females than males. Risk Factor Summary Intrinsic mechanical factors Bone mineral density Bone geometry Skeletal alignment Body size and composition Risk Factor Summary Physical training

2 Physical fitness Volume of training Pace of training Intensity of training Recovery periods Evaluating the painful athlete History Pain location, duration, timing, NIGHT PAIN? Previous injuries, ie. Ankle sprain? Training progression Girls - menstrual history General Exam Flexibility, strength symmetry, joint ROM, biomechanics, limb length Examination Physical signs include: Intense localized tenderness Localized periosteal thickening, Percussion of the bone distant from the symptomatic site may elicit pain at the site of concern. A vibrating tuning fork (128 Hz) placed at the suspected fracture site may suggest stress reaction. (poor sensitivity) Radiographic Diagnosis Plain Radiography Insensitive 5 Year Study of UCLA Track Athletes 73% confirmed by MRI Remain X-ray Negative. AMSSM Annual Meeting, Orlando, Fl Bone Scan MRI CT The high risk stress fractures that may develop complications, delayed union or nonunion.from: STRESS FRACTURES by Brukner, Bennell and Matheson. Blackwell Science Neck of the femur Pars interarticularis Patella Anterior cortex, midshaft of tibia Medial malleolus Talus Femoral Neck First Described by Earnst, 1964 Journal of Trauma. History The patient typically complains of groin pain, perhaps only with weight bearing and may have an antalgic gait. Examination May elicit pain with passive end range of motion at hip. + Hop Test Key Point - Cannot find palpable tenderness. Femoral Neck Fracture location is important to determine treatment. Tension side, superior neck, fractures are at considerable risk of displacement, avascular necrosis, non-union and malunion. Early diagnosis and surgical management is necessary. A period of nonweightbearing is recommended. Femoral Neck X-ray X-rays are often negative. Femoral Neck Bone Scan Bone scan should be considered if there is clinical suspicion for these stress fractures. Femoral Neck MRI MRI is exquisitely sensitive and far more specific than bone scan for femoral neck stress fracture. Femoral Neck Compression side Remove from offending activity. Nonweightbearing until pain settles. Refrain from running activities. UCLA MRI Study 70% of cases with bone edema resolves by 12 weeks. Tension Side or Displaced Fractures Internal Fixation Femoral Shaft Femoral shaft - Less common than the femoral neck stress fractures. Complaints are vague with a mild, deep thigh soreness. Military recruits 50% were transverse fractures of distal 1/3, and almost of half of these were displaced. Athletes mid medial or posterior medial cortex. (Adductor attachment) Femoral Shaft Physical clues include: deep thigh tenderness, antalgic gait, positive Hop test, and a recently described "fulcrum test" by Johnson. Hang test the thigh hangs over the exam table while the examiner pushes down on the distal femur. These are usually treated nonsurgically with average heal times of 8-14 weeks. Female HS Freshman Stopped mid season due tibial stress fx.

3 Swim Team Started Track training aggressively. One month - Deep pain left thigh cross country season Late September Left groin/hip pain FROM, No tender spot, +hop test X-rays negative MRI High School Track Six weeks anterior knee pain Behaved like patellofemoral syndrome. Physical therapy. Not improving, therapist requests permission to make orthotics. Request denied. Let s look at this again. Freshman x-c Late September Proximal left leg pain x 2 weeks Exam No visible sign of injury Exquisitely tender proximal medial cortex. X-ray Negative Clinical diagnosis only- tibial stress fx Followup January Wrestling ok Tried to start running and pain returned. X-ray again Question Healed or Not? Maybe we should find out. Posterior Tibial Stress Fx Anterior Tibia Jumping sports "dreaded black line" (DBL), show a higher incidence of nonunion. Track Athlete with Ant. Tibia Stress Fx- Rx with EBI Bone Stimulator Olympic Athlete Presents to clinic AFTER games competition. Pain to lower leg. Has been able to go. Tender along anterior ridge. Foot Tarsal Navicular Brukner noted a very high rate of tarsal navicular stress fractures (35% of all stress fractures) in track athletes. Often overlooked Average time to diagnosis 4 months. Symptoms are often vague. A cramping sensation and pain to the dorsal midfoot should raise suspicion of this fracture. Exam - Tenderness over the N Spot Average time to return to sport is 5.6 months. Coach hears talk on navicular stress fx Tells athlete - maybe that s what s wrong Athlete - 3rd world championships, 1:43.x at 800 meters 4 months pain Recent diagnosis of metatarsal stress fx Tarsal Navicular Collect opinions Surgical vs. nonsurgical Treated 6 weeks nonweightbearing boot 4 more weeks weightbearing boot Gradual return to training Racing one year later Olympic team - Sydney 2000 s Lesser metatarsal stress fractures Sacral Sacrum relatively uncommon. Patients present with buttock pain. These must be differentiated from the more common SI joint dysfunction. Plain radiography is insensitive. Bone scan or MR is necessary to firmly diagnose this problem. Sacral Stress Fracture in a Runner Summary Suspected Stress Fracture Clinical Exam X-ray weeks after symptom onset; 73% remain negative MRI - Stress Fracture protocol STIR images T1 images if indicated Stress fracture rest determined by location, intensity, future demands

4 Stress Fracture Progressive training Caution through the vulnerable window at 3-4 weeks. Attention to bone health Calcium Menstrual status Muscular strength reduces shock loads to bone Equipment - ie. Shoes Tendinitis Achilles Diagnosis Iliotibial Band Syndrome Anatomy Pain locations s Patellofemoral pain syndrome Diagnosis Retracking Quads Pelvic stabilizers Stairs sideways Bridges The Female Athlete Triad Eating Disorders Anorexia Nervosa Bulimia Nervosa Disordered eating. Amenorrhea Definitions <9 periods per year. >3 months with period Incidence Reproductive age women 5% All female athletes 20% High risk sport 50% Amenorrhea Cause? Stress Energy Balance Osteoporosis Bone deposition through age. Fracture risks Males too!! Stress fracture rates:athletes with regular menses vs. athletes with irregular menses. Athletic Nutrition Macronutrients Carbohydrates Fats Protein Micronutrients Fe++; Fe+++ Hydration Issues August - hot weather training Sports Drinks Race finish collapse Signs and Symptoms Decline in Peak performance Heavy burning muscles and nausea Ice-craving or Pica Craving for cold, raw, crisp vegetables The Elite Athlete Claims of up to 80% of elite women distance athletes are iron deficient are not true. Based on serum ferritin <25mg. Iron Def. Anemia in female general population 10% are iron deficient 3-5% are anemic Rare among men. Anemia is relative Nonanemic (hgb >12) women given iron vs. placebo for 6 weeks.

5 Iron group became fitter and faster. Concept - functional anemia. Nonanemic by hgb, but room for improvement if iron stores are low. Hinton, PS. Iron Supplementation improves endurance after training in irondepleted women. J Appl Physiol 88: VO2 study Nonanemic women (>12) ferritin <12 vs. >12 Lower VO2 max, and lower hgb 13.6 vs University of Oklahoma Screened athletes 20% of female volleyball and basketball players with hgb <12; Soccer players 50% <12. Mechanisms Iron Loss Gastrointestinal Small contributor Menstrual Small contributor Sweat Small contributor - Need to sweat 5-50 liters/day to lose 1mg of iron. Iron losses in Sweat, Am J Clin Nutr One hour of moderate exercise in heat = only 6% of iron typically absorbed in one day. Iron Insufficient dietary iron Principle culprit RDA for women - 15 mg Many elite women runners eat <2000 cal / day which would usually provide 12 mg / day. Vegetarian diets may provide adequate iron intake, but less is bioavailable than iron in meat. -IDADiagnosis Hbg: <14 in males; <12 in females Ferritin:<10-15mg/l - probably iron deficient Red cell indices: MCV <85 implies IDA Reticulocytes: if low in the presence of anemia this suggests IDA. Therapeutic trial of iron - if uncertain of cause, then give iron supplement one month and then retest. Iron Deficient AnemiaManagement Red meat contains heme iron which is easier to absorb. Avoid coffee or tea with meals. Supplement reducing substance:vitamin c (orange juice);fe +3 to Fe +2. Cook occasionally in iron pots and skillets. Eat poultry or seafood with beans or peas (the animal protein enhances vegetable iron absorbtion) Iron Supplementation - Ferrous Sulfate TID Iron Deficient AnemiaIron Supplementation Iron ingestion with vitamin c and citrate is better absorbed. Particularly following exercise. Hydration Issues Fluid status is critical to: Competition Performance Practice Performance Injury avoidance VCD Prevalence Conclusions: Five percent of athletes were IS +, with EIB comorbidity observed in 53%of these subjects. Misdiagnosis of IS as EIB is common. The lack of a β2 -agonist response in combination with postexercise serial spirometry can be useful in excluding solitary IS and confirming EIB diagnosis. Change Direction Shoe Components Historic Shoe Goal #2 Control Motion The higher eversion the higher injury frequency? Forefoot Varus causing late stance phase pronation, seen as heel valgus Problem of leveragebarefoot running Problem of leverageshoe running Problem of leverage Retrospective study: Patellofemoral pain syndrome (PFPS) In patients with a PFPS they found increased adduction-abduction knee moments increased internal-external rotation of the knee O -uptake and shoe comfort 2 Current concepts in athletic shoes Reduction of lever arm rotational and abductional forces at the knee Individualization of motion cushioning fit