Bone Stress Injuries- Managment and Prevention

[Aaron Hartstein]

Hey guys,

Here is an article I reviewed after reading Cameron’s journal club case. I actually reference it a lot for patient’s presenting with posterior tibialis symptoms. It has definitely helped guide my clinical decision making when trying to decide if or where on the spectrum (Fig 1.) a patient may fall in respect to a bone stress injury and how I should modify their activity. Table 3. shares a really helpful graded running program with return to run guidelines for patients that you believe have a bone stress injury.

Here’s the web address for the JOSPT article: http://www.jospt.org/doi/pdf/10.2519/jospt.2014.5334

•How have you guys managed suspected stress reaction/stress fractures with athletes who have a difficult time with activity modification like Cameron’s athlete?

•Have you clinically seen a patient present with compartment syndrome as a result of this problem?

#stressthebonestress

[Kyle Feldman]

So this was a good read
I liked how they broke down the causes, the types and how to treat.

I have been using the harvard medicine return to running program which is very detailed and gives a runner some great info. It is pretty similiar to this one in the text

The flow charts were also great to give the big concepts and how the cycle can begin and continue but also how you can stop it

The feedback tools for gait training, will help in the clinic as well. Having all of this information is great for some of those runners who think they know all about running. Give some of this information about running form and how training can affect this is key. This article has a lot of the good info all together

Without being able to do much unloading without a pool or alter G we do not have the ability to do much of the final things from the article

[Kyle Feldman]

I have a 23 year old runner who is having LBP with running with poor lumbo pelvic control, decreased hip ext and dural signs. I gave her basic lumbo pelvic HEP and she did not do because she said she got frustrated and quit. She does not want to modify activity and has cried in 2 of the 3 visits. She wears orthotics and full support shoes (since she was 15) and says she could not run without them. She is type A to the max

I had to sit down and talk to her about PT and what we can do to help these symptoms

After reading this article there are some great points I can use about why we are shutting her down (to reduce the stresses on the irritated tissues), why we are adjusting form (she is not 15 anymore and her daily routine is not school and sports), and why strengthening these muscles with motor control is so important.

Even though I do not think she is having stress reaction I think this brings great talking points

[Aaron Hartstein]

Comments from Anisha (my current student from VCU)

The article addresses how physical activity history can be protective against BSI. This reminded me of a class discussion we had where we talked about how there are a lot more stress fractures in basic training now than there used to be. This has been attributed to children not being as physically active as they used to be, so they did not engage in proper bone loading when they were young, making them more susceptible to stress fractures. I think that if we are able to address it, an important factor to prevent stress fractures as well as many other health issues would be for children to be more physically active in general.

I found it interesting that switching to a softer terrain for training does not necessarily decrease BSI risk, but rather the change could be problematic. I think that is a good education point for runners who maybe are starting to get injured and decide to switch terrains, to a treadmill or softer surfaces to try, to be cautious.

Another aspect of this article I found interesting was how protective calcium and Vitamin D supplements can be in preventing BSIs. However, as a physical therapy student, I wasn’t sure how in our scope it was to recommend dietary supplements. Is this something you guys address or recommend to patients you feel could benefit from the addition of these?

[Aaron Hartstein]

I certainly think it’s within our scope to discuss dietary needs with patients as it relates to their energy requirements for their respected activity level and healing; especially when bone stress injuries are on the table.

I’ve had one patient over the last 6 months where this conversation definitely needed to take place; 16 y/o high school female running cross country and track that presented with all the positive signs of the female athlete triad. I typically don’t recommend supplements but rather approach it with a discussion with the patient on how much/what their eating throughout their day and potentially make recommendations more related to caloric intake and examples of nutrient dense foods. For this particular patient, I clued the mom in on the findings of my exam since she wasn’t with us during the evaluation and reiterated the importance of caloric intake to meet the energy demands of patient’s activity level and how the adverse effects present clinically. I also spoke with the referring physician to communicate my concerns and discussed a plan for further follow-up with a sports nutritionists for a more in-depth consultation if the patient’s condition and complaints weren’t improving.

[Aaron Hartstein]

Good points, Anisha. If I suspect that a patient has a BSI and that dietary factors may be a major contributing factor, I think it’s certainly necessary to address these issues with the patient and also communicate suspicions and findings with the referring physician. It may not always be an easy conversation to have (especially with a teenage athlete), but I think linking appropriate nutrition with performance and the patient’s ultimate goal of returning to running at the highest level will motivate the patient to address nutritional needs and ultimately he/she will be more receptive to your suggestions. We’re fortunate here at UVA to have a nutritionist, so certainly utilizing all of your resources is important in getting the patient back to optimal health and performance.

Like Kyle, I also like the fact that the article provided a gradual return to running protocol. This is a great resource to provide patients with exact dosage when a patient asks you where to start with a walk-run interval program.

[Aaron Hartstein]

Great article, Steph. I thought this was an awesome overview with some great resources that I will definitely reference when treating patients with suspected BSIs. Unfortunately I have not had the opportunity to treat any as of yet. I am remembering any injury my sister had while training for a marathon however- she had B anterior shin pain (and a past history of tibial stress fracture prior) while running that eases with rest. She swore by compression socks and kinesiotaping which apparently eliminated her pain with running. Anyone have any experience in an actual clinical setting with success with this?

Anisha- great comments! Regarding switching terrains, the article mentions leg stiffness can increase on softer terrains but not enough to make the GRF more than on less compliant surfaces. I think you are definitely right to proceed with caution when switching terrains for injured runners, however I think we could trial switching terrains from non-compliant to semi compliant (such as from asphalt to a rubber track) with some success where as a more extreme switch (asphalt to sand or even grass where ankle instability, etc. may lead to altered biomechanics) may be more detrimental. So picking the right kind of switch and using are clinical judgement there might be successful versus encouraging them to choose any “soft” surface.

Regarding discussing dietary supplements, I was definitely hesitant to do this as a new grad as we are conditioned that medications are out of our scope. After working with Myra, however, I realized this was a huge area of knowledge we have that can help supplement our treatment (more wholesome care is best!). We have discussed the benefits of concentrated tart cherry juice, omega 7, magnesium, etc with patients. When initially concerned about practicing out of my scope, it was a nice reminder that these supplements are over the counter and a patient can go and get them without any medical guidance. Our guidance will allow them to make more informed decisions than if they went picking through on their own. I would never order that a patient take this (just recommend they look into it) and always encourage a patient to read the label and to be sure nothing is contraindicated on the label based on meds they are on, etc. and if they have further concerns, to talk with the pharmacist or their MD.

[Kyle Feldman]

I am all about telling patients a healthier way of life. Talking about drinking more water, balanced diets, vitamins

Things that we learned even in undergrad are things many of these poeple are not exactly familiar with. We have an upper hand with our knowledge that we can give some basic information to them but in the end can be huge
NO, We are NOT dietitians or nutritionists but we are living our own healthy lifestyles and can give basic recommendations to help guide people down a better path.

Like the mentors talk about, we are treating the whole person and this is another aspect

What is everyone elses thoughts?

[Aaron Hartstein]

great discussion so far team– I thought the article was insightful regarding return to running protocol (powered by some big names in our field as well). In regard to discussing diet and restrictions, it is definitely hard to do, especially with an individual who may already be “diet sensitive” in nature. I have had this discussion with one of my female athletes before. Her male physical therapist at the time had tried to discuss this with her but was not breaking through with her, therefore he asked me to treat her a few sessions and then talk nutrition, diet, female athlete triad. Also, I recommend to an extent an overall healthy lifestyle, and I think being a health care provider allows us to professionally recommend and suggest this, as well as patient’s may abide by a professional recommendation.

[Kyle Feldman]

good stuff Cam
Sometimes a different voice and a similiarty can help get those points across

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