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Image this, your new affected person this afternoon is a runner with a historical past of a sacral stress fracture. She’s simply obtained the outcomes of a DEXA scan which revealed osteopenia. Operating is absolutely necessary to her. It lifts her temper and her social life revolves round it so she’s determined to get again. How will you assist her safely return to working and optimise her bone well being?
Firstly in these conditions, it’s necessary to think about why they’ve low bone mineral density (BMD). There are a number of concerns for this that must be assessed and addressed (NOTE: The roles beneath will range considerably relying on native providers so please see them as a tough information):
Picture impressed by Bone well being and the masters runner by Raiser et al. (2024)
We developed a Bone Well being Questionnaire as a part of the clinic sources we offer in Operating Repairs On-line. It could actually assist you to determine a few of these components to allow them to be assessed in additional element. Use the hyperlink beneath to obtain your free copy.
Obtain your free Bone Well being Questionnaire
A key consideration for runners with bone stress accidents is Relative Vitality Deficiency in Sport (REDs). Relative vitality deficiency is assumed to happen when an athlete isn’t consuming sufficient to fulfill the vitality calls for of each sport and each day life. REDs have an effect on a number of bodily methods together with bone well being, menstrual operate, metabolism, sleep and cardiovascular and muscle operate. Consequently, it could actually impair well being and efficiency and improve damage threat.
REDs is a fancy subject that normally requires multidisciplinary administration. For extra on this see the current IOC Consensus Assertion – Mountjoy et al. (2023).
Instruments have been developed to display screen for REDs, together with the current IOC REDs CAT2 which features a site visitors gentle model system to information return to sport. Nonetheless, it does level out that, “The analysis of REDs is a medical analysis to be made by a sports activities medication doctor“.
Picture: REDs Well being Conceptual Mannequin from Mountjoy et al. (2023)
A wise first step if you happen to’re working with a runner and also you’re involved about their bone well being or vitality availability is to contact their physician/ GP.
You’ll be able to share the outcomes of the Bone Well being Questionnaire with them and focus on your considerations. It additionally supplies the chance to discover whether or not specialist enter similar to a referral to a sports activities medication doctor is indicated.
Some therapists or sufferers might desire to refer on to a sports activities med doctor, particularly if a extra pressing opinion is required. The important thing level right here is to search the precise help for the affected person. There are exams and investigations that we are able to’t present for them and are mandatory for his or her care so they should see the precise individuals throughout the multidisciplinary group.
Let’s look at a few of these components with this runner that’s seeing you for an appointment. Let’s name her Mel.
Related historical past
Mel is a 27-year-old feminine, she’s not pregnant and she or he stories a traditional menstrual cycle. She has no different recognized medical historical past other than the sacral stress fracture. Given her age and presentation, she’s unlikely to be perimenopausal (which may have an effect on bone well being).
Sacral stress fractures are a trabecular-rich web site for bone stress damage. These typically have larger associations with diminished vitality availability, menstrual dysfunction and low BMD so we have a tendency to research these components in such accidents.
Mel has no related household historical past, she’s a non-smoker and drinks minimal alcohol.
Components which may be managed by the GP
Mel will not be taking any common medicine which may influence bone well being (similar to steroids or anticonvulsants). Her GP might prepare blood exams and advise on remedy choices if Mel is low in Calcium, Vitamin D or Iron or has impaired thyroid operate. When acceptable a GP may prescribe medicines to enhance bone well being similar to bisphosphonates however they might not be indicated for Mel. For extra on this subject Iqbal et al. (2019)
Components which may be managed by a physio (or different therapist)
Once we discover Mel’s earlier coaching we uncover it was excessive quantity with a big proportion of high-intensity work and little restoration, that is more likely to result in fatigue and overload the bone. With the intention to match this coaching round work Mel tends to run early within the morning and sacrifices sleep so as to take action. Sleep is considered necessary to bone well being and lack of sleep might improve the chance of BSI.
At current Mel will not be working so we’d need to make sure that her vitality availability and bone well being wants have been met previous to planning a return. It could be smart to plan this inside a multidisciplinary group (contemplating the knowledge beneath). Mel could possibly cross-train to keep up health and assist psychological wellbeing however she would want to make sure she fuels sufficiently to do that.
When Mel is able to return to working we may advise Mel on her coaching construction and development plus guarantee restoration is deliberate into her weekly schedule and coaching blocks. Mel’s purpose is to run a sub 3-hour marathon, for this it could be finest to group up with a Operating Coach for his or her enter on optimising efficiency whereas coaching at a manageable stage.
We might additionally assess Mel’s energy and conditioning wants and plan a programme together with her to handle them. That is more likely to embrace progressive strengthening and plyometrics as each can enhance bone well being. These must be launched on the proper stage of therapeutic and rigorously deliberate into the programme to forestall overload and fatigue.
The place specialist enter could also be wanted
Mel tells us she makes use of a calorie-restricted food regimen alongside high-volume coaching to keep up a wholesome weight (her BMI is nineteen). This will likely have resulted in vitality deficiency which has impacted her bone well being and should have an effect on a number of well being domains.
Mel mentions she’s been suggested to cut back her working previously however finds it very tough to take action, as an alternative her train has elevated over time regardless of it inflicting conflicts together with her accomplice. Mel additionally stories she’s very irritable and harassed when unable to train. These will be indicators of train dependancy or compulsion.
Contemplating these findings I might advocate a referral to a Sports activities Drugs Doctor. They may assess Mel in additional element and consider the suspected REDs.
I might additionally counsel a referral to a Registered Dietician or Sports activities Nutritionist to make sure Mel’s vitality and diet wants are being met.
There are screening instruments that can be utilized for suspected train dependancy however it could be smart to discuss with a psychological well being skilled similar to a Sports activities Psychologist who’s skilled on this space.
In abstract, the next steps will be useful when working with a runner with osteopenia or osteoporosis:
- Contemplate why they’ve low BMD – take a superb historical past to determine these components (and use the Bone Well being Questionnaire)
- If bone well being components haven’t been addressed then focus on your considerations with the runner’s physician/ GP together with what specialist referrals and investigations could also be indicated
- If treating an energetic bone stress damage then permit ample time for therapeutic and intention to maintain train pain-free
- Develop a rehab programme to handle their wants and optimise bone well being
- Set standards for return to working to make sure they’re each bodily and psychologically prepared for his or her sport
- Advise on coaching construction, development and restoration to realize their targets
- Monitor their response to maintain them on monitor!
I recognize this can be a advanced subject so for extra info please see our module on Bone Stress Accidents in Operating Repairs On-line the place we’ll information you thru the steps above in additional element.
