PREVENT STRESS FRACTURES

It is two weeks away from the 28^th Steamtown Marathon. After training all spring and summer for the first seven Steamtown Marathons, not a Columbus Day Weekend goes by without my thoughts of this great event.

I would like to introduce this topic with some marathon history. In 490 B.C. Athens was under attack by the Persians and was outnumbered more than two to one. The Athenians fought bravely and defeated the enemy in the town of Marathon. The victory kept the intruders 26 miles away from Athens. To keep the anxious citizens of Athens calm, leaders immediately ordered a foot soldier, Phedippides, to run to the capital city to share the news. Phedippides ran, in full armor, for 26 miles from Marathon to Athens, delivered the message and died immediately. Now, people do the same thing of their own free will!

Each year at this time, dozens of runners preparing for the Steamtown Marathon come to my office with severe shin pain known as shin splints. Unfortunately, in many of these athletes, this problem can lead to a much more severe and advanced problem with shin splints called a stress fracture.

What is a stress fracture?

A stress fracture is fatigue damage to bone with partial or complete disruption of the cortex of the bone from repetitive loading. While standard x-rays may not reveal the problem, a bone scan, and MRI will. It usually occurs in the long bones of the leg, mostly the tibia but also the femur (thigh) and foot. Occasionally, it occurs in the arm.

Who is at risk?

10-21% of all competitive athletes are at risk for stress fractures. Track, cross country and military recruits are at greatest risk. Females are twice as likely as males to have a stress fracture. Other athletes at risk are: sprinters, soccer and basketball players, jumpers, ballet dancers are at risk in the leg and foot. Gymnasts are also vulnerable in the spine while rowers, baseball pitchers, golfers and tennis players can experience the fracture with much less frequency in the ribs & arm.                                                              

The problem is much more prevalent in weight bearing repetitive, loading sports in which leanness is emphasized (ballet, cheerleading) or provides an advantage (distance running, gymnastics).

Stress fractures usually begin with a manageable, poorly localized pain with or immediately after activity such as a shin splint. Over time, pain becomes more localized and tender during activity and then progresses to pain with daily activity and at rest.

Causes of Stress Fractures:

• Overuse, Overload, Over training – is the number one cause. Running too many miles with too much intensity with too much frequency is the perfect formula.
• Inadequate Fitness Level – or activity level prior to the stress fracture. For example, the high school runner takes the summer off and then quickly accelerates his/her program to quickly for cross-country in August/September.
• Poor Biomechanics – when your feet hit the ground the forces are absorbed and transferred to the rest of the body. If the biomechanics of feet are not perfect, then the forces are not absorbed, and another body part bears too much force. For example, flat or pronated feet poorly absorb the shock and pull the tendons of the foot and shin.
• Recent Change in Training Schedule – sudden increased intensity or speed
• Recent Change in Running Surface – sudden change to a hard or soft surface
• Recent Change in Footwear – shoes too hard or too soft, too much control or too little control, too much pronation or too much supination
• Overweight – running with an extra 10 pounds and attempting to return to running as a method of weight loss
• Underweight – the underweight female athlete is at high risk for stress fractures. If underweight and have a history of menstral irregularities or and eating disorder, the risk of stress fracture increases significantly
• History of Stress Fractures – makes the athlete two times as likely to have another

Treatment & Management:

• Alternate Training – cross train with non-weight bearing activities: bike, swim, elliptical
• Gradually Build Up Fitness Level – wean into activity 1-2 miles, then add ½ mile at a time
• Correct Biomechanics - Orthotics, Running shoes, see a Podiatrist
• Gradual Change in Training Schedule
• Gradual Change in Surfaces – ½ run on soft surface, ½ run on hard surface
• Gradual Change in Footwear – walk in new shoes first, then run 1-2 miles
• If Overweight – gradual exercise with diet, not too much too quickly
  • Mix run & walk every 10 minutes
• If Underweight – improve diet maintain healthy body fat%
• Consult Family Physician – early management often involves immobilization, rest, pain medicine 4-6 weeks for healing.
  • non weight bearing cross training such as the recumbent bike, swimming, elliptical
  • physical therapy modalities such as ultrasound, cold with electrical stimulation, biomechanical taping or orthotic supports, and exercises for foot, ankle muscles.

Visit your doctor regularly and listen to your body.     

Read Health & Fitness Forum Next Monday/Sunday: Preparing Your First Aid Kit For the Steamtown Marathon

EVERY MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” via Blog

EVERY SUNDAY in "The Sunday Times" - Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in hard copy

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopedic and sports physical therapy in Scranton and Clarks Summit. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine. For all of Dr. Mackarey's articles, visit our exercise forum!

SAFE RETURN TO DRIVING AFTER INJURY OR SURGERY

I enjoy the privilege of working with people recovering from a wide variety of medical conditions. Many of these conditions can directly affect activities of daily living, particularly, the ability to drive safely: orthopedic and sports injuries, fractures, sprains and strains, joint replacements, hip fractures, shoulder and elbow surgeries and spinal fusions. Despite the many different types of problems, there is one question that is invariably asked, “When can I return to driving?” Unfortunately, the answer is not as simple as the question because it depends on many factors. Furthermore, the implications, such as a serious accident causing further damage to the injury or surgical site or harm to someone else, are significant and possibly critical. So, the next time you ask your physician this question, please follow instructions and be patient…remember, it could be your child or grandchild running into traffic to chase a ball and you would want the driver to be at optimal function to apply the brakes!

Impact of Not Driving

In our culture, the inability to drive has a significant impact on lifestyle and livelihood. A study published in the Journal of Bone and Joint Surgery, found that 74% of those unable to drive due to injury or surgery are dependent on family and most of the remainder depend on friends. 4% of those unable to drive have no help at all and more than 25% suffer major financial hardship.

The report also found that family physicians, orthopedic surgeons, podiatrists, and physical therapists are keenly aware of this dilemma but often fail to communicate effectively to patients about driving. Most medical professionals express serious concerns about liability regarding return to driving following an injury or surgery. They feel that there is a lack of data to support decisions and inadequate communication among each other. They agree that they must do a better job communicating with patients and their families so they can better prepare for a period of time during their recovery in which they cannot drive.

Recent studies published in the Journal of the American Academy of Orthopaedic Surgeons (JAAOS) and the Journal of Foot and Ankle Surgery (JFAS),determined that there are two significant components in the decision of safely returning to driving after an injury or surgery; the time required for healing and the time required for a return of function. Additionally, it was found that those wearing a surgical shoe or walking boot demonstrated a significantly slower braking response time even in healthy/non-injured individuals wearing the shoe/boot.

Time for Adequate Healing

During the time required for healing, in addition to the fear of an additional trauma from a motor vehicle accident to the healing body part, there is a general concern about the potential damage that may come from over using the body part to drive before it is adequately healed. For example, a healing fracture in the right lower leg might be compromised or delayed if one must suddenly and forcefully apply the brakes. Also, during this time, it is not unusual for post-injury or post-surgery patients to use pain medications, including narcotics. This will also compromise judgment and reaction time while driving.  

Time for Adequate Function

Most orthopedic conditions heal in 6 to 8 weeks. However, as many of you may fully know, once a cast or splint is removed, you are not ready to run or jump. Depending on the severity of the injury, it may take many weeks of aggressive physical therapy to regain strength, range-of-motion, agility and dexterity to function at a safe level for a full return to daily activities, including driving.

Driving Requires the Whole Body

The current research reinforces the fact that driving safely requires good function of the entire body. For example, just because you broke your shoulder bone but did not fracture your right leg does not mean that you are able to drive safely. Wearing a sling after arm surgery also compromises driving. First, you need a stabilized and healed injury prior to driving. Then, you must work in rehab to make modifications to return to safe driving. Apply the same scenario to injuries or surgery to the spine (neck and lower back).

GENERAL GUIDELINES: RETURN TO NORMAL BRAKING REACTION TIME AFTER SURGERY (JAAOS)

*Based on research using driving simulators

7 TIPS TO KNOW WHEN YOU ARE READY TO DRIVE:

1. You have physician’s approval that you are healed enough not to do any damage to the injury.
2. You can use your arms to touch your forehead and opposite shoulder without significant pain.
3. You can walk with minimal pain and minimal limp.
4. You can put 50% of your total weight on the involved leg (especially the right).
5. You have adequate range of motion at the hip and knee (bend the hip 70-90 degrees, extend your knee to -10/-5 degrees and bend your knee to 80-90 degrees without pain).
6. You can drive in empty parking lot and practice without difficulty.
7. You are wearing a surgical shoe or boot that does not involve surgery or fracture healing (tendonitis or plantar fasciitis) and with your physician or podiatrists approval, the device can be removed without causing pain upon seated weight-bearing and gas/brake simulation.

Remember, every case is unique and there is no substitute for communication with your orthopedic surgeon, podiatrist, family physician and physical therapist.

Visit your doctor regularly and listen to your body.     

Keep moving, eat healthy foods, exercise regularly, and live long and well!

EVERY MONDAY – Read Dr. Paul J. Mackarey “Health & Exercise Forum!” via Blog

EVERY SUNDAY in "The Sunday Times" - Read Dr. Paul J. Mackarey “Health & Exercise Forum!” in hard copy

This article is not intended as a substitute for medical treatment. If you have questions related to your medical condition, please contact your family physician. For further inquires related to this topic email: drpmackarey@msn.com

Paul J. Mackarey PT, DHSc, OCS is a Doctor in Health Sciences specializing in orthopaedic and sports physical therapy in Scranton and Clarks Summit. Dr. Mackarey is in private practice and is an associate professor of clinical medicine at Geisinger Commonwealth School of Medicine. For all of Dr. Mackarey's articles, visit our exercise forum!