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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. Operating is absolutely necessary 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 necessary to contemplate 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 fluctuate 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 assets we offer in Operating Repairs On-line. It could show you how to 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 Vitality Deficiency in Sport (REDs). Relative power deficiency is believed to happen when an athlete isn’t consuming sufficient to fulfill the power calls for of each sport and day by day life. REDs have an effect on a number of bodily programs together with bone well being, menstrual operate, metabolism, sleep and cardiovascular and muscle operate. Consequently, it might impair well being and efficiency and improve damage threat.
REDs is a fancy matter 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 smart first step when you’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 focus on 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 proper help for the affected person. There are checks and investigations that we will’t present for them and are obligatory for his or her care so they should see the proper folks inside the multidisciplinary crew.
Let’s study 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 apart from the sacral stress fracture. Given her age and presentation, she’s unlikely to be perimenopausal (which might have an effect on bone well being).
Sacral stress fractures are a trabecular-rich web site for bone stress damage. These typically have larger associations with diminished power 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 that could be managed by the GP
Mel will not be taking any common treatment which may influence bone well being (equivalent to steroids or anticonvulsants). Her GP could organize blood checks and advise on remedy choices if Mel is low in Calcium, Vitamin D or Iron or has impaired thyroid operate. When acceptable a GP also can prescribe medicines to enhance bone well being equivalent to bisphosphonates however they will not be indicated for Mel. For extra on this matter Iqbal et al. (2019)
Components that could be managed by a physio (or different therapist)
After we discover Mel’s earlier coaching we uncover it was excessive quantity with a big share 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 necessary to bone well being and lack of sleep could improve the chance of BSI.
At current Mel will not be operating so we’d wish to make sure that her power availability and bone well being wants have been met previous to planning a return. It could 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 might 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 crew up with a Operating 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 along with her to handle them. That is more likely to embody progressive strengthening and plyometrics as each can enhance bone well being. These have to be launched on the proper stage of therapeutic and fastidiously 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 plan alongside high-volume coaching to keep up a wholesome weight (her BMI is nineteen). This will likely 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 operating up to now however finds it very tough to take action, as a substitute her train has elevated over time regardless of it inflicting conflicts along with her companion. Mel additionally experiences she’s very irritable and pressured when unable to train. These may be indicators of train dependancy or compulsion.
Contemplating these findings I might suggest a referral to a Sports activities Medication Doctor. They’ll 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 dependancy however it might be smart to check with a psychological well being skilled equivalent to a Sports activities Psychologist who’s skilled on this space.
In abstract, the next steps may be useful when working with a runner with osteopenia or osteoporosis:
- Contemplate why they’ve low BMD – take an excellent historical past to determine these components (and use the Bone Well being Questionnaire)
- If bone well being components haven’t been addressed then focus on 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 permit enough time for therapeutic and purpose 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 attain their targets
- Monitor their response to maintain them on observe!
I respect it is a complicated matter so for extra info please see our module on Bone Stress Accidents in Operating Repairs On-line the place we’ll information you thru the steps above in additional element.
