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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 acquired 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 working 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 concerns for this that should be assessed and addressed (NOTE: The roles beneath will differ 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 assets we offer in Working Repairs On-line. It could allow you to determine a few of these elements 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 power deficiency is believed to happen when an athlete isn’t consuming sufficient to satisfy the power calls for of each sport and every day life. REDs have an effect on a number of bodily techniques together with bone well being, menstrual perform, metabolism, sleep and cardiovascular and muscle perform. Because of this, it could possibly impair well being and efficiency and enhance damage danger.
REDs is a fancy subject that normally requires multidisciplinary administration. For extra on this see the latest IOC Consensus Assertion – Mountjoy et al. (2023).
Instruments have been developed to display screen for REDs, together with the latest IOC REDs CAT2 which features a site visitors gentle model system to information return to sport. Nevertheless, 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 if you happen to’re working with a runner and also you’re involved about their bone well being or power 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 issues. It additionally gives the chance to discover whether or not specialist enter corresponding to a referral to a sports activities drugs doctor is indicated.
Some therapists or sufferers could choose 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 suitable help for the affected person. There are exams and investigations that we will’t present for them and are mandatory for his or her care so they should see the suitable folks inside the multidisciplinary staff.
Let’s study a few of these elements 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 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 website for bone stress damage. These usually have better associations with lowered power availability, menstrual dysfunction and low BMD so we have a tendency to analyze these elements in such accidents.
Mel has no related household historical past, she’s a non-smoker and drinks minimal alcohol.
Elements that could be managed by the GP
Mel isn’t taking any common remedy that may influence bone well being (corresponding to steroids or anticonvulsants). Her GP could organize blood exams and advise on therapy choices if Mel is low in Calcium, Vitamin D or Iron or has impaired thyroid perform. When acceptable a GP also can prescribe medicines to enhance bone well being corresponding to bisphosphonates however they is probably not indicated for Mel. For extra on this subject Iqbal et al. (2019)
Elements that could 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. As a way 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 working so we might need to be certain that her power availability and bone well being wants have been met previous to planning a return. It will be smart to plan this inside a multidisciplinary staff (contemplating the knowledge beneath). Mel might be able to cross-train to keep up health and assist psychological wellbeing however she would wish 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 aim is to run a sub 3-hour marathon, for this it might be greatest to staff up with a Working 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 should 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 have resulted in power deficiency which has impacted her bone well being and will have an effect on a number of well being domains.
Mel mentions she’s been suggested to cut back her working up to now however finds it very troublesome to take action, as a substitute her train has elevated over time regardless of it inflicting conflicts together with her associate. Mel additionally stories she’s very irritable and harassed when unable to train. These could be indicators of train habit or compulsion.
Contemplating these findings I might advocate a referral to a Sports activities Drugs Doctor. They are going to assess Mel in additional element and consider the suspected REDs.
I might additionally recommend a referral to a Registered Dietician or Sports activities Nutritionist to make sure Mel’s power and vitamin wants are being met.
There are screening instruments that can be utilized for suspected train habit however it might be smart to consult with a psychological well being skilled corresponding to a Sports activities Psychologist who’s skilled on this space.
In abstract, the next steps could be useful when working with a runner with osteopenia or osteoporosis:
- Think about why they’ve low BMD – take an excellent historical past to determine these elements (and use the Bone Well being Questionnaire)
- If bone well being elements haven’t been addressed then talk about your issues 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 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 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 objectives
- Monitor their response to maintain them on monitor!
I admire it is 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.
