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After reading this article, I will likely have stress fracture on my initial differential list for most runners I see who have lower extremity pain. During my subjective exam, I would like to get a good idea of recent changes in mileage, when during the running process pain occurs (both at what point during the gait cycle and whether it occurs during or after the run), and what the patient’s typical diet consists of.
During my objective exam, I would plan on palpating the area and performing some bone loading tests if stress fx was on my differential. If the athlete had a history of stress reaction/fx, I would perform a functional assessment including SLS and single limb squats as well as a running gait analysis if the athlete was cleared to run again. In our clinic, we use the Hudl Technique app to analyze gait frame by frame to better pick up abnormalities. As far as providing education for an athlete returning to run following stress fx, I would want them to be aware of their weekly mileage and I would advise them to increase their weekly mileage by no more than 10% from week to week.
I’m curious to know what kind of advice regarding return to run that you all like to give to your pts.
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I think this article provides an excellent example of asking specific differential-driven subjective questioning. Questions regarding running surface, changes to training, running shoes, pain descriptions, when in their running cycle/time pain comes on, and types of running (long-distance vs. sprinters). While I am not currently seeing patients of this population, I think being aware of these types of questions when stress fracture is on a differential is extremely important.
I really like the charts in this article as well as the factors listed that can modify the load applied to bone. I like the way the article breaks up the biomechanical factors, training factors, muscle factors, running surfaces, shoes, and the bone’s ability to resist load without damage. This breakdown of factors helps me formulate a list of potential influencing factors and prioritize what I can address. While I cannot change all of these factors, I think it is important to examine the factors that I can change in my objective exam and in subsequent treatment sessions. After reading this article, I think making a point to utilize a more “running specific” objective exam is critical with these patients. Watching them run and perform SL tasks is a must.
Tyler, I usually use the Brigham and Women’s Hospital return to running protocol. It provides strategies for advancement and regression as well as what pain is “okay” and what is “not okay” in regards to return to training. (Like I said, I don’t see a lot of these patients, but this is one I have used in the past).
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*Subjective history: Making sure to be very specific with when they feel pain, at what point in their running gait cycle as well as how long into their run – in order to be more specific with hypothesis on what bone is affected. Question whether their pain resolves as running continues or does it remain throughout and cease afterwards, etc. *This article highlighted the importance of a thorough subjective history as special testing and imaging have low sensitivity. Asking the right questions in terms of past history (and even maternal history) of BSIs and asking specific questions about diet and training changes can help guide decision-making.
*Suspicion on differential: Have they had past BSIs, have they had a recent increase in training intensity or change in running surface, footwear, diet, etc. Suspicion of female athlete triad after subjective may have but BSI higher on my list.
*objective after h/o stress fracture: Do they have tenderness to palpation, warmth to touch. Gait and single leg task analysis would be important. Furthermore, addressing possible predisposing factors (muscle strength and control, core, knee, ankle stability) in modified positions depending on stage and irritability.
*treatment: I though this article was great for it’s emphasis on education and being very specific on return to running program. I have found that runners are quick to ignore pain and run through injury so having a specific plan is important (when to stop, when to progress, and what they can do in the mean time to maintain cardiovascular fitness) -
This article has opened my eyes to some of the risk factors that may lead to BSI and how to better screen and treat this in the clinic. Subjectively, I would like to clarify where the pain is coming from, diet and nutrition, endocrine/ hormonal influences, current medications, and bone quality. I would also like to ask about extrinsic factors such as running surface, shoe type and recent increase in activity levels such as speed or distance.
Objectively, I would like to watch them run, if they are cleared to do so. Their form and recognition of malaligned lower limbs/ abnormal movement patterns can have an impact on tis type of injury. Additional, functional testing such as SL activities and palpation are both important to look at especially to use as pre and post testing assessment tools over time.
I agree with what Sarah said in respect to education being a huge factor in this population. Typically, these athletes will want to return to running before their body is ready. This article lays out a great timeline to return to sport to be able to relay to the patient so they know when the guidelines to increase pace and time for running. Education on when this is appropriate and why they should allow for the proper time is huge in decreasing a reoccurring injury.
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Subjective: This article reminded me of the importance of getting a clear picture of how the symptoms have changed/progressed over the course of the injury. Specifically asking if the symptoms improve during the run or improve with warming up could be a helpful question when trying to rule out BSI. I think I can do a better job of getting more diet/nutrition information from the patient, especially when BSI is higher on the differential.
to be cont’d
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Objective: Progressively loading the system during the exam and looking for movement patterns or compensations that may explain why the injured region was overly stressed. Palpating in a methodical, repeatable pattern to improve accuracy.Treatment/education: Making sure the patient understands that returning to running without re-injury requires appropriate loading. Prescribing cross training options to help increase compliance with a gradual walk/jog program. For the patient with history of multiple stress fractures, keeping a training log would be beneficial to help them regulate their mileage.
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