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Bone Stress Injuries in Runners – October Newsletter

Bone Stress Injuries in Runners

Holly Warner, DPT

Sapphire PT just returned from a weekend course that focused on bone stress injuries in runners. The course defined the female triad spectrum and provided screening tools to assess athletes’ risk of developing bone stress injuries.

A stress fracture diagnosis is a diagnosis no runner wants to hear. It is often a season ending injury and recovery is long and filled with cross training fun. Though, these injuries are often preventable and risk factors can be assessed using simple screening tools.

The female triad has been redefined as a spectrum rather than 3 distinct diagnoses. The triad spectrum consists of three key components:

  1. Optimal energy availability to low energy availability
  2. Normal menstruation to hypothalamic amenorrhea (absence of menses)
  3. Optimal bone health to osteoporosis. Individuals can fall anywhere on the spectrum.

When there is a relative energy deficit, abnormal menstruation, and/or low bone mineral density one is at risk for developing a stress fracture/bone stress injury. The female triad coalition recommends that female athletes undergo annual screening with a self-reported questionnaire to assess risk of developing a stress fracture during the season.1 These questions help to assess the magnitude of risk and include questions about eating habits, history of stress fractures, age of menarche and current frequency of menses. There are also male parallels to the female triad. Assessing the male athlete’s risk factors is also key to maintaining good bone health in this population.

Low energy availability can happen without the presence of an eating disorder and often happens without the athlete knowing they are going into an energy deficit. Inadequate caloric intake can lead to abnormal hormone production. Hormonal imbalances can lead to menstrual dysfunction or hypogonadism in the male athlete, reduced bone mass, loss of muscle, and suppressed metabolism. All of these factors increase risk of developing a bone stress injury and negatively affect athletes overall performance.2

Besides assessing risk based on the triad, there are other key factors that play a role in maintaining good bone health when training. These include:

  1. Rest – Allow for adequate rest and recovery, get enough sleep, and make sure your easy runs are easy and that rest days are rest days.
  2. Mileage – Too much mileage too fast increases risk for developing bone stress injury, and significant changes in training volume or pattern can increase your risk
  3. Running intensity – Use the Rate of Perceived Exertion scale (RPE value) to help pick up on days you are more tired/fatigued and the frequency of these runs. Track your hard runs and the frequency of these runs including speed workouts and more hilly runs to pick up on significant changes in running patterns.3
  4. Dietary factors – Adequate intake of Vitamin D and calcium help maintain good bone health. Meet with your primary care provider or sport nutritionist for guidance on recommended daily intake values or supplementation.2

Fitness and Aging:
Filtering through facts and misinformation

John Fiore, PT

Aging impacts my health and fitness.
False: Maintaining fitness is not possible since I am over 40 or 50 or 60 or 70 years old. A September 2018 article in Readers Digest listed 13 exercises one should avoid if he or she is 50 years old. Yes, this caught my attention as I endorse every one of the 13 exercises if done correctly. While I do not consider Readers Digest as a credible source for exercise and fitness news, I will list the 13 exercises, all of which have benefits if done correctly:

image of weight lifting while balancing1. Running Stairs
2. Spin Classes
3. High Intensity Interval Training 4.Hot Yoga
5. Push-ups
6. Squats with Weight
7. Bench Press
8. Burpees
9. Pull-ups
10. Crunches
11. Dead Lifts
12. Jumping Lunges
13. Sprints

The degree to which fitness is impacted by aging is based on physiology, genetics, medical history, exercise choices, and lifestyle choices. The largest factor influencing fitness as one ages (insert your definition of what “aging” represents), however, is lifestyle choices. Physiological changes associated with aging include a change in cardiac function (i.e. Max heart rate, cardiac output), a decrease in lean muscle mass, a decrease in strength, a decrease in flexibility, a decrease in connective tissue elasticity, and a decrease in bone density. Genetics also plays a large role in the physiological cards we are dealt at an early age. Joint stiffness in the spine may be virtually absent to some, while others may develop a more limiting genetic form of spinal degeneration such as ankylosing spondylitis (HLA-B27).1 Prior medical history and orthopedic injuries (joint and ligament injuries, fracture history, overuse injury history, bone density baseline) should guide the degree of impact your body will tolerate during exercise. But what about the factors each and every one of us can influence regardless of our genetics? How is one to sort through the conflicting information available on the subject of fitness and aging? Understanding your present fitness, fitness goals, and recognizing your past and present medical issues will guide lifestyle fitness choices to allow you to maintain fitness for years to come.

As a physical therapist and an endurance athlete, I view proper exercise as the most effective way to positively influence fitness with age. I quantify this statement with the words proper exercise because many factors determine how well your body will respond to certain exercises. Running is a relatively high impact form of exercise. If done correctly (efficiently and following a consistent, gradual training program), however, running may be tolerated well into one’s 60s and 70s. Exercise consistency is crucial for life-long fitness. Regular exercise (3 days per week minimum with 5 days per week preferred) must address the areas of fitness most impacted by age. Strength training must be included as physiology has shown a decrease in lean muscle mass and strength naturally occurring with age. Speed must be included as our fast twitch (speed) muscle fibers are replaced by slow twitch (endurance) muscle fibers with age. Flexibility training must be included to promote joint health and reduce osteoarthritis, and cardiovascular exercise must be included for circulatory health and to maintain a healthy body weight. To reduce joint-related pain, minimize impact loading and vary your workout routine accordingly.

So what is the magic exercise? What is the key to fitness with age? Where do I buy the DVD or infomercial product to give me life-long fitness? No single exercise exists which combines all of these necessary components into one activity. picture of skiing downhillTraining, therefore, begins with finding an exercise form you enjoy (i.e. running, cycling, swimming, skiing). The next step is to develop a functional strength training program (with the help of a qualified physical therapist or trainer) aimed at improving your power and efficiency. Add to your strengthening program a dynamic stretching program to insure healthy joint motion and mobility. Mix up your workouts to decrease the adaptation effect created in the body when you run the same 4-mile loop every day. Finally, have an annual physical to make sure your heart is healthy, your blood levels are within normal limits, and your cholesterol and blood pressure are normal.

Fitness beyond the 20s and 30s have many faces. From the person who has just been told by their physician to lose weight and reduce their blood pressure to the 60-year old athlete who defies both years and gravity, fitness in the second half of life does not have to be elusive. Life experiences, life choices, environmental factors, genetics, and dedication to health and fitness all impact our fitness later in life. Call Sapphire PT to find out more about how you can realistically attain your fitness goals at any age.

References – Bone Stress Injuries in Runners
1 Aurelia Nattiv, MD. Lecture Presented: Female Athlete Triad Coalition
Consensus Statement on Treatment and Return to Play of the Female
Athlete Triad; September 21-22, 2018; Park City, UT.
2 Adam Tenforde, MD. Lecture Presented: Bone Stress Injuries:
Epidemiology; September 21-22, 2018; Park City, UT.
3 Rich Willy, MPT, PhD. Lecture Presented: The Use of wearable tech in
load monitoring; September 21-22, 2018; Park City, UT.

References – Fitness and Aging
1 Brown MA et al. Clin Exp Rheumatology; 2002. 20: S43-S49.