Week 3 Lecture 3A - Stress Fractures Flashcards by Michael Obi

BMD – Bone mineral density

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Disordered eating – whole spectrum of behaviours - poor nutritional choices

Amenorrhea – abnormal menstrual cycle

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Some of these symptoms will be hard to treat once developed.

Have to recognize theses sxs as clinicians and be able to refer.

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RMR – Calories you burn to stay alive (breathing and things like that

Eee – walking, exercise, etc

Want to take in enough calories to support calorie burn

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EDNOS – 70% of clinically eating disorders. Doesn’t meet criteria for the classifications.

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Eumenorrhea – normal menstrual cycle

Primary – individual never starts a normal menstrual cycle

Secondary – started normal cycle and then stops

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During puberty/adolescence is the most important time to build up BMD.
It’s all down hill after 30 years old.
If peak BMD was never that high you’ll reach the threshold where you’re more likely to fx earlier than someone else.

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It changes the actual structure to be more susceptible to fx.

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Sports that are aesthetically judged

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Someone who is trying to compete at a higher level and think being lean is the way to do it will compromise their overall health. Sometimes health isn’t a motivating factor, but more so performance.

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A lot of repeated stress injuries – history of other stress fxs/bone injuries should make you want to explore that more closely.

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Ask pts what they had for breakfast ? Have to explain that you can’t recovery as quickly if you don’t take in calories. Healing takes calories. Food is fuel and it is important for their recovery.

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Femoral Stress Fractures

Mechanism/Presentation:

Training errors: (undertraining/overtraining) - Recent (decrease/increase) in frequency, intensity or duration of exercise

Poor mechanics - Poor energy absorption

Two main reasons for femoral stress fx

Not absorbing impact well

Often times it is both of these reasons

overtraining; increase

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Stress Fractures

Stress fractures occur when repetitive load applied to bone is (lesser/greater) than its reparative capacity

Contributing factors:
Training errors
Anatomic and biomechanical factors
Underlying bone health

Homeostasis is out of wack. Being broken down faster than being built up.

Pt who has rigid supinated foot and not absorbing impact well (anatomic and biomechanical factor)

Underlying bone – already have osteoporosis will make them more susceptible.

greater;

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Fatigue – person that comes in and used to run 20 miles a week and now they are running 60 to train

Insufficiency – got out of bed and felt pain. Could be underlying metabolic bone disease.

Abnormal stress – decreased BMD and excessively training.

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Femoral Stress Fractures

Examination Findings:

Complaints:
Gradual increase of hip/groin/thigh or (lateral/medial) knee pain.
May notice increased pain with (NWB/weight bearing) activities- Antalgic gait possible
Resisted testing of femur may be painful -(any direction)
Potential ROM deficits secondary to pain

Hurts when they load it.

Antalgic – could be a limp

Resisted testing – creating torque through that fx and it won’ t feel good when doing resisted testing

medial; weight bearing;

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Femoral Stress Fx ``` Diagnosis is challenging: Diffuse / radiating pain Non specific findings Difficult to palpate History ``` “Classic diagnostic triad” History of recent (decrease/increase) in repetitive stress Pain (increases/decreases) with activity, (increases/decreases) with rest Pain around the (distal/proximal) femur Can radiate down the thigh. Ask if it is superficial or if it is deeper? – if it is deeper, more likely fx of femur rather than soft tissue Difficult – hard to get to the femoral neck

increase; increases; decreases; proximal;

Imaging should be the next step after suspecting femoral fx. It can be on the tension side, compression side. Bone likes (tension/compression), gets harder and lays down more bone, it is weaker and less stable with (tension/compression). Tension is more serious.

compression; tension

Put them in crutches and stop what was causing that increased load.

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Tension sided fx top left | Compression sided fx bottom right pic

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If the femoral head starts to move on the femoral neck it’s a problem – pic to the right

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Osteonecrosis - the femoral head will die Malunion – doesn’t heal Malalignment – changes the angle of the femoral neck which will lead to early degeneration

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Bone scan – goes to areas that are metabolically active. | If something shows up, you don’t’ know what it is, but we know something is there.

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Stop painful activity they are doing Do things that won’t load the fx – can encourage them to do those type of things.

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Can do all of these things as the fx is healing

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WB LE exercises – lunges, squats, step up/downs Work on NM control as they are doing their functional movements

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PHASES are guided by bone healing and symptoms. They’ll go back for imaging and see if everything is going well.

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Athletes who have bone stress injuries – start them on this It creates a pressure difference so you can unload at least 20% of your body weight and you can increase that gradually.

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Surfaces: Treadmill Vs Asphault In vivo tibial strain Percutaneous strain gauges medial tibia (Milgrom, et al) ``` Significantly (lower/higher) (48%-285%) running on asphalt vs treadmill Axial compression strain Tension strain Compression strain rate Tension strain rate ``` Tissues on the body don’t like to be loaded quickly

higher;

Gradually increasing longer run time and intervals. Start them on treadmill > track > then to where they want to run long term

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Are the muscles that comprise the groin adductors or abductors?

Adductors

People get those injuries by an acute episode where the muscle is stretched , stopping and changing directions, eccentric contraction due to the stretch. Tendinopathy – overuse – repetitive stress injury Exam findings – Resisted (ABD/ADD), passive (ABD/ADD), and palpation

ADD; ABD

Any muscle injuries – contract it, stretch it, poke it

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Osteitis Pubis Instability of pelvis Muscle imbalance between (hip flexors/abdominal) and (abductor/adductor) muscles Abnormal (horizontal/vertical) motion of pubic symphysis Single leg standing radiographs: Flamingo view >2cm displacement Chronic stress injury to pubic bone (kicking) - Bone marrow edema on MRI The adductors are strong and hypertonic, and the abs are weak which creates a muscle imbalance due to the different forces pulling on the pelvic ring. Too much motion up and down between the bones. If it shifts more than 2 cm there is instability in the pubic symphysis.

abdominal; adductor; vertical;

Widening of the symphysis, kind of jagged, reactive sclerosis (white stuff around the pubic symphysis) Flamingo view – right side is elevated

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Increased movement as there is abutment against the acetabular rim. People with osteitis pubis will also have SI joint pain because the pelvic ring moves more than it should.

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Pelvic compression test –looking for reproduction of pain

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Core stabilization- want pelvic ring more stable Reduce tone –adductors tend to be stronger than abdominals and hypertonic.

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Inguinal hernia – part of viscera is coming through abdominal wall. With the sports hernia – it is injury to the muscle or fascia.

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They all attach around this area and that is where the epicenter of the pain will be

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A lot of strong adductors and if the abdominals aren’t strong it will overpower them and cause a tear.

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A lot of sensory innervation in this area.

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Pain in the adductors because it is hypertonic. Can refer pain to the testicles

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Core Injury Pelvic instability secondarily occurs as a result of imbalance between the (TA/rectus abdominis) and (abductor/adductor) muscles

Rectus abdominis; adductor;

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FAI – Femoral acetabular impingement The core injury is less painful

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Core Injury Signs and Symptoms: chronic pain, often occurring only (after/during) exertion. Sharp burning pain localized to the (upper/lower) abdomen and inguinal region, that later radiates to the (abductor/adductor) region and potentially testicular region. Point tenderness at the pubic tubercle. Pain is often increased with resisted hip (flexion/extension), (internal/external) rotation, (abduction/adduction), and abdominal muscle contraction People do get better.

during; lower; adductor; flexion; internal; adduction

Cluster of 5 signs and symptoms indicative of Core injury (Superficial/Deep) groin or (upper/lower) abdominal pain Pain exacerbated by sport specific activities and is (increased/relieved) with rest -Sprinting, cutting, kicking, sit ups Palpable tenderness over pubic ramus at the insertion of the (Biceps femoris/rectus abdominis) and / or conjoined tendon Pain with resisted hip (abduction/adduction) Pain with resisted sit up

Deep; lower; relieved; rectus abdominis; adduction;

Adductor squeeze test - Do it with a BP cuff. Can measure how much force they can generate with the cuff and track it over time.

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Common Exam Findings Lower Cross Syndrome (Weak/Short) hip flexors (Weak/Short)abdominals (Anterior/Posterior) pelvic tilt (Weak/Short) gluteal muscles Address all of these

Short; Weak; Anterior; Weak

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Soft tissue mobilization of the tight adductors especially

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Train local stabilizers as opposed to global movers. Want pt to be able to contract and activate those muscles. Limbs – UE/LE

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Go posterior pelvic tilt, anterior pelvic tilt, and then go halfway. Can use pressure cuff – anterior pelvic tilt – bp cuff goes up, posterior pelvic tilt – cuff goes down, find neutral

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Hold 10 seconds and can work to 60 second hold

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Bent Knee Fall Out

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Laparoscopic – like arthroscope but not for joint

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Post Op Management Typically 8-12 weeks duration Precautions: (first 2 weeks) - Avoid trunk (hyperflexion/hyperextension), aggressive hip (flexion/extension) ROM - Avoid crunch activity (large contractions of rectus abdominis) Early: ROM hip, gluteal strength, TA activation, trunk stabilization. Begin and progress Functional Strength Progression weeks 3-4 through discharge. Don’t want to activate RA in first 2 weeks (crunch position)

hyperextension; extension;

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