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Lower Extremity Stress fractures in Female athletes: A clinical Review

Lower Extremity Stress fractures in Female athletes: A clinical Review. Brandon Mitchell, ATC Stony Brook university sports medicine. Learning opportunities. Review onset and diagnosis Risk factures associated with stress fractures Meanings for clinicians. Incidence of occurrence .

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Lower Extremity Stress fractures in Female athletes: A clinical Review

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  1. Lower Extremity Stress fractures in Female athletes: A clinical Review Brandon Mitchell, ATC Stony Brook university sports medicine

  2. Learning opportunities • Review onset and diagnosis • Risk factures associated with stress fractures • Meanings for clinicians

  3. Incidence of occurrence • Female > Male (2, 9) • 9.2% vs 3.0% Military • 9.7% vs 6.5% Athletes • Longer Training > Shorter Training (3, 5) • > 16 hrs per week were ~2x likely to have a stress fx than < 4 hrs per week • Active > Sedentary (8, 9) 24% occurred in 1st 3 wks Military training 76% occurred weeks 4-9 Military training

  4. Symptoms • Gradual onset • Increase in pain with load bearing activity • Typically localized • Pain with Standing Heel Raise • Pain ascending/descending stairs

  5. Diagnosis • Clinical Exam • X-Ray • MRI

  6. Radiographs

  7. Female Athlete Triad • Amenorrhea / Oligomenorrhea • Low Bone Mineral Density / Osteoporosis • Disordered Eating / Low Energy Availability http://www.femaleathletetriad.org/for-athletes-coaches/what-is-the-triad/

  8. Risk factors • External Factors • Training Regiment • Training surface • Lower Body Alignment • Internal Factors • Foot Structure • Nutrition • Bone Density • Hormone Balance

  9. Training • Regiment • Routine • Distance • Pace • Cross Training & Off Days  Supplemental Training • Surface • Soft surface • Wood Floor • Roads / Asphalt • Track • Trails

  10. Lower body alignment- somatic dysfunctions • Sacroiliac Joint Rotations and restrictions • Pelvic Rotations • Pelvic Upslips • Leg Length Discrepancy • False positive • Actual Discrepancy

  11. Foot Structure & Mechanics • Supinating Foot • More rigid • Less compensatory biomechanics • “Normal” motion through foot and ankle joints • Stress dispersed through foot, ankle, and low leg • Pronating Foot • More mobile • Limited Dorsiflexion at Ankle • Mobility at midfoot to compensate • Depression of Navicular (fallen medial arch) • Internal Rotation of Tibia Clinical Corrections: Clinical Corrections: Neutral Shoe Overpronator Shoe (stability) Low leg stretching Arch Supports Maintain foot & ankle motion Orthotics Ankle mobility

  12. Nutrition • Balanced Diet • You are what you eat! • Macronutrients (proteins, carbs, fats) • Micronutrients • Calcium • Vitamin D • Iron (Fe)

  13. Bone Density • Measured by Dual Energy Xray Absorptiometry (DEXA) • T Score • Z Score • Impacted by Nutrition and Hormone Balance (4, 10) • <Ca & Vitamin D  < BMD • Dysmenorrhea  < BMD • Reptitive impact < odd impact (4, 7) • Runners lowest total body BMD (6, 7) Wolman, pg 1015

  14. Hormone balance • Amenorrhea • Absence of menstrual cycle  low BMD, early onset menopause (4, 10) • Oligomenorrhea • Infrequent menstrual cycle  low BMD, fluctuation of weight (4, 10) • Dysmenorrhea  Increase risk of injury (1, 10) • Oral Contraceptives • Good or Bad?

  15. Repeated Stress Fractures • Labwork • DEXA Scan • Conservative management • Bone Stimulation modality

  16. Thank YOu

  17. References 1. Barrow GW, Saha S. Menstrual irregularity and stress fractures in collegiate female distance runners. Am J Sports Med. 1988; 16(3): 209-216. 2. BruknerP, Bennell K. Stress fractures in female athletes. Sports Med. 1997; 24(6): 419-429. 3. Chen YT, Tenforde AS, Fredericson M. Update on stress fractures in female athletes: epidemiology, treatment, and prevention. Curr Rev Musculoskelet Med. 2013; 6: 173–181. 4. CuttiP, Steele R, Shrier I, et al. Re-defining normal: bone mineral density in elite female athletes. Br J Sports Med. 2011; 45: 341. 5. Loud KJ, Gordon CM, Micheli LJ, Field AE. Correlates of stress fractures among preadolescent and adolescent girls. Pediatrics. 2005; 115(4): 399 -406. 6. MuddLM, Fornetti W, Pivarnik JM. Bone mineral density in collegiate female athletes: comparisons among sports. J Athl Train. 2007; 42(3): 403–408. 7. Nichols JF, Rauh MJ, Barrack MT, Barkai HS. Bone mineral density in female high school athletes: interactions of menstrual function and type of mechanical loading. Bone. 2007;41(3): 371-377. 8. Shaffer RA, Brodine SK, Almeida SA, Maxwell-Williams K, Ronaghy S. Use of simple measures of physical activity to predict stress fractures in young men undergoing a rigorous physical training program. Am. J. Epidemiol. 1999; 149(3): 236-242. 9. Wentz L, Liu PY, Haymes E, Ilich JZ. Females have a greater incidence of stress fractures than males in both military and athletic populations: a systemic review. Military Medicine. 2011; 176(4): 420-430. 10, Wolman RL. Bone mineral density levels in elite female athletes. Ann Rheum Dis. 1990; 49(12): 1013–1016.

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