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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 de facto 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 working 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 concerns for this that should be assessed and addressed (NOTE: The roles beneath will fluctuate 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 sources we offer in Working Repairs On-line. It may well enable you to establish 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 methods together with bone well being, menstrual operate, metabolism, sleep and cardiovascular and muscle operate. Consequently, it may possibly impair well being and efficiency and improve 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 visitors mild fashion system to information return to sport. Nevertheless, it does level out that, “The prognosis of REDs is a medical prognosis to be made by a sports activities drugs doctor“.
Picture: REDs Well being Conceptual Mannequin from Mountjoy et al. (2023)
A smart first step in case 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 possibly can 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 might desire 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 best assist for the affected person. There are assessments and investigations that we are able to’t present for them and are mandatory for his or her care so they should see the best folks inside the multidisciplinary workforce.
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 experiences a standard menstrual cycle. She has no different recognized 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 higher associations with diminished 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.
Components which may be managed by the GP
Mel is just not taking any common medicine which may affect bone well being (equivalent to steroids or anticonvulsants). Her GP might prepare blood assessments and advise on remedy choices if Mel is low in Calcium, Vitamin D or Iron or has impaired thyroid operate. 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)
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 considered necessary to bone well being and lack of sleep might improve the danger of BSI.
At current Mel is just not working so we might wish 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 workforce (contemplating the data beneath). Mel might be able to cross-train to take care of 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 working we might 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 finest to workforce 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 should be launched on the proper stage of therapeutic and rigorously deliberate into the programme to stop overload and fatigue.
The place specialist enter could also be wanted
Mel tells us she makes use of a calorie-restricted eating regimen alongside high-volume coaching to take care of a wholesome weight (her BMI is nineteen). This may occasionally 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 scale back her working previously 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 associate. Mel additionally experiences she’s very irritable and pressured when unable to train. These could be indicators of train habit or compulsion.
Contemplating these findings I’d suggest a referral to a Sports activities Drugs 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 power 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 could be useful when working with a runner with osteopenia or osteoporosis:
- Think about why they’ve low BMD – take a very good historical past to establish these elements (and use the Bone Well being Questionnaire)
- If bone well being elements 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 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 targets
- Monitor their response to maintain them on observe!
I recognize this can be a advanced 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.
