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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. Working is admittedly essential 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 operating and optimise her bone well being?
Firstly in these conditions, it’s essential to think about why they’ve low bone mineral density (BMD). There are a number of issues for this that have to be assessed and addressed (NOTE: The roles beneath will differ considerably relying on native companies 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 Working Repairs On-line. It may possibly aid you 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 Power 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 every day life. REDs have an effect on a number of bodily programs together with bone well being, menstrual perform, metabolism, sleep and cardiovascular and muscle perform. In consequence, it could impair well being and efficiency and enhance damage threat.
REDs is a posh 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 for REDs, together with the current IOC REDs CAT2 which features a site visitors mild fashion 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 drugs doctor“.
Picture: REDs Well being Conceptual Mannequin from Mountjoy et al. (2023)
A wise first step in the event you’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 talk about your considerations. It additionally supplies the chance to discover whether or not specialist enter equivalent to a referral to a sports activities drugs doctor is indicated.
Some therapists or sufferers could favor 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 will’t present for them and are needed for his or her care so they should see the precise individuals throughout the multidisciplinary crew.
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 experiences a standard menstrual cycle. She has no different identified medical historical past except for 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 usually have higher associations with lowered vitality availability, menstrual dysfunction and low BMD so we have a tendency to analyze 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 isn’t taking any common treatment that may affect bone well being (equivalent to steroids or anticonvulsants). Her GP could prepare blood exams and advise on remedy choices if Mel is low in Calcium, Vitamin D or Iron or has impaired thyroid perform. When applicable a GP may prescribe drugs to enhance bone well being equivalent to bisphosphonates however they will 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)
After 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 regarded as essential to bone well being and lack of sleep could enhance the chance of BSI.
At current Mel isn’t operating 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 will be smart to plan this inside a multidisciplinary crew (contemplating the knowledge beneath). Mel might be able to 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 operating we may advise Mel on her coaching construction and development plus guarantee restoration is deliberate into her weekly schedule and coaching blocks. Mel’s objective is to run a sub 3-hour marathon, for this it could be greatest to crew up with a Working Coach for his or her enter on optimising efficiency whereas coaching at a manageable degree.
We’d additionally assess Mel’s power and conditioning wants and plan a programme along with her to handle them. That is more likely to embrace progressive strengthening and plyometrics as each can enhance bone well being. These have to 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 weight-reduction plan 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 operating prior to now however finds it very troublesome to take action, as an alternative her train has elevated over time regardless of it inflicting conflicts along with her accomplice. Mel additionally experiences she’s very irritable and harassed when unable to train. These might be indicators of train habit or compulsion.
Contemplating these findings I’d suggest a referral to a Sports activities Medication Doctor. They’ll assess Mel in additional element and consider the suspected REDs.
I’d additionally recommend 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 habit however it could be smart to consult with a psychological well being skilled equivalent to a Sports activities Psychologist who’s skilled on this space.
In abstract, the next steps might be useful when working with a runner with osteopenia or osteoporosis:
- Take into account 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 talk about 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 enable adequate time for therapeutic and goal to maintain train pain-free
- Develop a rehab programme to handle their wants and optimise bone well being
- Set standards for return to operating 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 admire this can be a complicated subject so for extra data please see our module on Bone Stress Accidents in Working Repairs On-line the place we’ll information you thru the steps above in additional element.
