Now that part one of bone injuries has had some great exposure, we thought that now would be a good opportunity to release part 2 of 3. As a quick refresher, in part one we discussed pathology continuum (excessive load leading to bone stress, from bone stress to stress fracture and stress fracture to complete fracture), and people who are at heightened risk of bone injury. In this post we will progress and discuss new topics – how we determine and detect bone injury, and categorise high versus low risk fracture sites with reasoning behind the classification.
HOW TO DETECT BONE INJURY
As clinicians we rely heavily on a patients subjective history. This is when we first determine whether or not you may or may not have bone related injury. Patients will often tell a story which often highlight what kind of pathology may be present and where on the continuum it may lie. In regards to bones the stride team (physiotherapist and podiatrist) will ask questions around:
⁃ A specific incident when symptoms started (often came on slowly and progressively worsened)
⁃ What symptoms (determine pathology continuum) are most prevalent
⁃ The area in question (is it subject to load) and ground reaction forces
⁃ The associated symptoms (type of symptoms, night symptoms, symptoms under active or passive movement / both)
⁃ Exercise history and training load
⁃ General health
⁃ Previous medical history (bone injury)
In addition to subjective and objective findings the stride clinicians can and may refer patients for further investigations (MRI, X-RAY and CT imaging). This is because these types of scan have the ability to confirm suspicions of clinicians and determine best course of action and management.
HIGH VERSUS LOW RISK FRACTURES
Approximately one third of long distance runners will suffer from some form of bone related injury at some point in their exercise history. The more alarming fact is that 10-12% of these runners will sustain a subsequent bone stress injury in the following year. However the exact location will always vary as each individual will load his or her skeleton differently.
When categorising bone injuries we can put them in high and low. High is if there is a delay in unionisation or nonunion, with a high chance of progression to complete fractures:
⁃ Femoral neck
⁃ Medial malleolus
⁃ Base of the second metatarsal
⁃ Great toe sesamoids
Low recovery occurs with low incidents of complications, without the need for aggressive interventions such as prolonged modified weight bearing or surgery:
⁃ Posteriomedial tibia
⁃ Fibular – lateral malleolus
However, it is imperative we explain that fractures can change between high and low. This depends on the magnitude of pathology found on imaging, patients medical history, and the continuation of symptoms when symptoms are expected to have subsided. When warranted the stride clinicians will utilise trusted sports clinicians to pursue a multidisciplinary approach. This is to ensure optimal patient management.