I am looking for some commentary on stress reactions of the lower extremity in recreational endurance athletes. In the spirit of the Boston Marathon this past Monday, I think this is an appropriate topic. I have had the privilege of treating 4 patients with stress related injuries directly related to training for Boston. As we all know stress reactions/fractures are very delicate to work with, for many reasons.
First, and probably foremost, is personality associated with the injury. To me these fall into 2 categories: the crazy, insane, stop-at-nothing endurance athlete type and the highly motivated, new to training, have to meet my goals type. Both can be difficult to reel in and get on board with the appropriate treatment plan.
Second issue is what exactly are we dealing with. A stress fracture or a stress reaction. Just like any other diagnosis…. if we catch it early and correct the abnormal stresses we can get the patient back to sport much quicker. If it has progressed to a fracture, we obviously have to respect the fracture healing in additional to identifying the abnormal stress.
The final issue is the actual treatment plan. What is right??? Often times the plan goes something like this: immobilize, rest, rehab, and return to activity. What often is missing is the correction of biomechanical faults? These patients did not develop stress related injuries randomly….. at least not typically. There is often an underlying, unidentified biomechanical issue…. or perhaps it was simply a change thatoccurred in what the patient had been doing. For instance…. one of the patients training for Boston came to me with a diagnosis of a cuboid stress reaction. She was 10 weeks before marathon monday and had been told that she was out of the race. Easy to say for a doctor that hadn’t trained for a year and raised the required $3800 or so for running on a charity exemption. She is well known to my clinic. On evaluation she reported that she had rested for 2 weeks and was pain free for all activity except running. Pain was isolated over the cuboid. She had not strayed from her previously outlined training program. Her only change was her shoeware. She had changed 4 weeks prior from stability plus sneakers to Asics Gel Nimbus (neutral) shoes on a recommendation from a friend. Her mechanics are such that she is a severe overpronator and that was the final straw. A few weeks with no support and increasing mileage left her destined for trouble. Upon identifying this we decided to change her to Asics 2150 series sneakers (stability plus) and go with an OTC Vasyli orthotic with some varus FF and RF posting. We began a slow, gradual return to running program (100% painfree). Within 5 weeks she was back on track for her marathon training, albeit at a slowere, more controlled pace. She completed her marathon on Monday painfree.
So after a drawn out entry what is my point. Identifying underlying mechanics and the stage of injury can lead to much greater success in treating an otherwise frustrating and frustrated patient population. 2 of the stress injuries we worked with were able to complete their marathons. The other 2 were full stress fractures and were unable to run. We are working on making sure they make good on their goals next year.