Removing the Rust-A Seminar for the Seasonal RunnerRemoving the Rust-A Seminar for the Seasonal...
Transcript of Removing the Rust-A Seminar for the Seasonal RunnerRemoving the Rust-A Seminar for the Seasonal...
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Removing the Rust-A Seminar for the Seasonal Runner
David Bernhardt, M.D.Department of Pediatrics, Orthopedics and Rehab
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Objectives
• Formulate a plan to start running, improving your fitness
• Understand the possible intrinsic and extrinsic factors which may contribute to overuse injuries
• Guide return to activity if you are injured
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Resources
• UW Sports Medicine Clinic 263-8850
• UW Sports Physical Therapy Clinic 263-4765 – Gait analysis– Flexibility– Core strengthening program
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Resources
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Starting point
• Goals
• Training plan to reach your goal
• Flexible
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Training plan• Base – starting point depends on fitness
level
• Core strength– Core Running by Mark Verstegen
• Cross train
• Time to reach your goal
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Overuse Injuries
• Common cause of most running injury
• Stress fracture• Tendinitis
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Stress fracture
• Tiny cracks in bone
• “march” or “fatigue” fractures
• Bone fracture which usually results from repetitive overload
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BONE OVERLOAD• Imbalance between
bone formation and bone destruction
• Osteoblasts: bone matrix formation through production of type 1 collagen, non-collagenous protein and regulatory factors
http://sprojects.mmi.mcgill.ca/bonephysio/index.htm
• Osteoclasts: bone resorption
• Extracellular matrix– Collagen fibers– Ground substance– Inorganic matrix - Ca
and PO4
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Mechanical Load Bone Strain
Damage > Remodeling
Stress Reaction
Stress Fracture
Complete Fracture
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Mechanical Load
• Weight
• Intrinsic factors – skeletal, muscle, joint, biomechanical factors
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Strain
• Change in length per unit of length of a bone
• Repetitive strain usually results in microdamage
• Imbalance of damage and repair leads to stress continuum
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Risk of damage
• Magnitude and rate of introduction of the applied load
• Absolute number of loading cycles
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Risk Factors• Extrinsic
– Sport– Training – Equipment– Environment
• Intrinsic– Biomechanical
factors– Fitness– Gender
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Sprinters – high load, short duration– Foot: metatarsal, tarsal stress fractures
Distance runners – cyclic overload– Proximal stress fractures: tibial, femur
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Training Error
• Insufficient time for remodeling or repair
Increase training Increase # of boneremodelling units
Porous bone, Increase strain
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Training error• Increase in bone
loading cycles (miles)• Increased intensity
(speed)
• Sports camps• Year-round training
• HOW MUCH IS TOO MUCH?
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Equipment
Shoes Inserts
Attenuate load
Kinetic chain
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Intrinsic Risk Factors• Fitness
• Biomechanical Factors (Cavus vs planus foot)
• Muscle
• Gender
• Diet: eating disorders, low vitamin D
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Pronation
• Limited pronation increases the magnitude of impact loading
• Increases foot flexibility• Attenuates ground reaction impact
forces• Couples with internal rotation of tibia
during first half of stance phase
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Menstrual Hx & Bone Health• Extended periods of oligomenorrhea/amenorrhea
may have a residual effect on lumbar BMDDrinkwater B et al. JAMA 1990
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Menstrual history & Diet
• SF: older at menarche
• SF: hx of menstrual disturbance
• SF: higher score on EAT-40
• SF: restrictive dieting
Bennell KL Clin J Sports Med 1995
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Risk Factors among Young Female CC Runners
• N = 127• 18-26 yo• Stress fracture
confirmed by radiology test
• Baseline BMD, body comp
• Follow-up ave 1.85 y
Kelsey JL, Bachrach LK, et al. MSSE 2007: 39:1457-63
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Risk Factor• 891 female Marine recruits• 6.8% with total of 66 stress fractures• Initial 0.86 per 1000 TDE*• Subsequent 3.0 per 1000 TDE
• RF: slowest quartile, secondary amenorrhea
• *training day exposure
Rauh MJ, Macera CA, et al. MSSE 2006
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Diagnosis
• Pain localized close to a bone in the lower extremity
• Focal tenderness
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Diagnostic tests - xrays• Usually negative in
first 4 weeks
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Diagnostic tests - MRI
Sofka CM. Clinics in Sports Medicine 2006
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Diagnosis
• Stress reaction: negative xray, positive bone scan with focal tracer uptake
• Stress fracture: positive xray with periosteal rxn
• No clear difference in prognosis
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Diagnosis
• Stress reaction: negative xray, periosteal edema, marrow edema
• Stress fracture: negative xray, marrow edema, low signal in the intramedullary bone surrounded by edema
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Grading
• I: periosteal edema• II: more severe periosteal edema with
marrow edema on T2 images only• III: moderate to severe edema or
periosteum and marrow on T1 and T2• IV: fracture line present
Fredericson M et al. Am J Sports Med 1995
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Prognosis
• I: 2-3 weeks• II: 4-6 weeks• III: 6-9 weeks• IV: cast for 6 weeks and 6 weeks of
non-impact
Fredericson M et al. Am J Sports Med 1995
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Prognosis• Fracture line
correlates with longer rest time
Yao L et al. Acad Radiol 1998 (abstract)
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Location• Tibial (anterior
tibial*)• Metatarsal• Calcaneal• Tarsonavicular*• Fibular• Femoral• Femoral neck*
• Pelvic – ischial ramus, ischial tuberosity, sacrum
*High-risk stress fxs
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High risk
• Risk to progress to complete fracture– Tension side femoral
neck– Anterior cortex,
middle 1/3 tibia– Tarsal navicular
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Treatment principles• Rest – activity
modification• Equipment• Immobilization• Weight bearing• Nutritional concerns• Hormonal concerns• Bone stimulator?
• Non-impact exercise– Stairmaster– Elliptical– Water jogging
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Treatment
• Correct malalignment• Cross-train• Relative rest• Follow-up q 4 weeks• Allowed to return when non-tender on
examination and no pain with easy running
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Return to activity….
• PT consult
• Adaptation
• 5-10% per week rule
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Orthotics?
• Orthotic influence differs between running and walking
• Research filled with controversy regarding subject selection, measurement, results, individual foot patterns, kinetic chain
• Success in reducing pain may be more trial and error
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References• Bennell K.L., Malcolm S.A., Thomas S.A., et al. The incidence and distribution of stress
fractures in competitive track and field athletes: a twelve-month prospective study. Am J Sports Med 1996; 24 : 211-7.
• Corris EE. Tarsal navicular stress fractures. Am Fam Physician 2003; 67:85-90.
• Heiderscheit B, Hamill J, Tiberio D. A biomechanical perspective: do foot orthoses work? Br J Sports Med 2001; 35:4-5.
• Jones MH. Navicular stress fractures. Clin Sports Med 2006; 25:151-8.
• Kudo P, Dainty K et al. Randomized Placebo-Controlled, Double-Blind Clinical Trial Evaluating the Treatment of Plantar Fasciitis with an Extracorporeal Shockwave Therapy (ESWT) Device: A North American Confirmatory Study. J Orthop Research 2006; 24:115-123.
• Placzek R, Deuretzbacher G, et al. Treatment of Chronic Plantar Fasciitiis with Botulinum Toxin A. Clin J Pain 2006; 22:190-92
• Guten GN. Running Injuries. Saunders Publishing 1997.