Originally published in The Ottawa Citizen August 17, 2004
Original Title: The thin white line

CREDIT: Wayne Cuddington, The Ottawa Citizen X-rays, although the first test to be done, may not show a stress fracture. An MRI is better for diagnosis.

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The pressure and stress exerted upon the feet and lower extremities can be substantial. A common class of sports-related injury is stress fractures.

Stress fractures can be difficult to diagnose because they may not be seen on an X-ray immediately after an injury.

It should be suspected when the patient states that he or she can identify a specific region of bone pain. This is especially telling if there is a recent history of a new exercise routine or program, or an increase in exercise intensity or level.

Track and field sports account for more than 50 per cent of the stress fractures in men and 64 per cent in women. Platform diving and rowing, although not considered high-impact sports, may lead to stress fractures especially in the metatarsal bones of the feet (the bones that connect the foot to the toes) and the ribs. Softball, hockey, swimming and golf are not likely to cause fractures.

Although upper extremity and rib stress fractures do occur, they are much less common than the lower extremity stress fractures. The focus for this column will be on bones of the lower leg (tibia and fibula) and the feet.

The bones most likely to be affected are the tibia (shin bone) and the metatarsals. Fractures of the pelvis, femur (thigh bone), fibula (bone running parallel to the tibia in the lower leg) and some other bones of the foot occur less commonly.

The fracture is due to the repetitive injury of the bone usually from the pounding nature of the activity. This causes microfractures to form.

The injured or microfractured bone tries to repair itself. However, if the same activity continues, the microfractures coalesce into a stress fracture. It is like chipping a block of ice. Small cracks appear each time. Eventually, with enough chips, the ice will crack. The bone cannot keep up with repairing the damage and eventually cracks from the strain.

Although athletes do suffer from these fractures, non-athletes or deconditioned people beginning a new exercise program are at high risk for injury. Women are more likely than men to develop fractures. Sixty per cent of people who suffered from a stress fracture will develop another when they resume the same exercise regimen.

Half of all stress fractures in children and adults occur in the tibia, usually because of excessive running or jumping. Metatarsal fractures account for another 25 per cent of stress fractures and commonly affect the second and third metatarsal bones near the toes.

Other areas affected to a lesser extent are the fibula and a bone in the midfoot called the navicular bone.

Endurance athletes can develop fractures of the femur. They are rare but they have a high incidence of not healing.

Signs and symptoms that aid in the diagnosis of stress fractures include a dull ache or pain localized to a specific site in the lower extremity that worsens with weight bearing or exercise. The area may be swollen but the tell-all sign is pain with direct palpation.

A fracture of the femur can present as pain in the groin, front of the thigh or knee. The hip is painful to move.

X-rays, although the first test to be done, may not show the fracture; it may never appear on the X-ray, or it can take from two to 10 weeks before it can be seen.

A nuclear bone scan is able to detect early stages of stress fractures. MRI is better than regular X-ray tests for diagnosis and can outline the fracture better than a bone scan.

Nonsurgical interventions for the treatment of stress fractures include using ice, nonsteroidal anti-inflammatory drugs (NSAIDs) and resting the bone for several weeks or until the pain resolves. Warm-ups and stretching prior to resumption of activity is recommended. The exercise regimen should be gradually increased to avoid a new fracture.

Injury prevention includes pre-exercise stretching with a warm-up. This is especially important for tibial stress fractures. Light footwear and a smooth soft running surface such as a dirt path or grass will also reduce the fracture risk.

Some injuries may require casting or a special orthotic shoe. There is some evidence that using an aircast helps the athlete return to the activity sooner. Certain types of femoral fractures may require surgical repair. Each bone type has its own set of treatments and is best discussed with your doctor.

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Originally published in The Ottawa Citizen October 2 , 2003
Original Title: Bending over backwards to save your back

About 90 per cent of adults will experience acute back strain and pain in their lifetime. It is a leading cause of work absenteeism and reduced productivity in Canada and the United States. Interestingly, most back pain resolves regardless of the type of therapy used. Indeed, most will return to work within three months of the injury. The problem is some will continue to experience recurrent back strain and movement limitations.

Back strain does not necessarily come from excessive weight bearing, carrying heavy loads, falls or trauma. Many times it is the accumulation of physical stress and strain and improper back support over time.

Factors that contribute to back strain include the ergonomics of a workstation, the type of shoes one wears, the type of chair, foot rests, car and truck back supports and medical illness among others.

Most often back strain is due to small tears in the lower back muscles responsible for maintaining posture. Some other causes include herniated or ruptured vertebral discs and arthritis.

Without proper back support, the back muscles can stiffen and become susceptible to strain. Sitting or standing for long periods can also lead to low back strain. Add in lifting and moving of heavy objects or physical labour and the risk of back trauma increases.

There are some common principles to prevent back injury. Even for those with a healthy back these principles will prevent potential back strain over the long-term.

Physical exercise, walking, cycling, swimming and other activities, will help maintain muscle tone and strength. Losing weight will reduce the strain on the lower back as it tries to maintain your body’s upright posture. Modified sit-ups (crunches) will reduce the curve in your lower back, strengthening the abdominal muscles that support it and reducing the chance of injury.

People who have physically demanding jobs are “industrial athletes.” Many succumb to injury because they do not warm-up before work by stretching and participating in conditioning exercises.

Choosing the proper back support techniques depends upon the type of physical activity and the work environment.

Many people remain seated at their desk for hours. The weight of the legs pulls the hips forward and increases the curvature (lordosis) of the lower back. You can feel the strain and tenseness in these muscles.

Shifting or rocking your hips side to side while seated can relax the pelvic muscles. Placing both feet on a footstool pushes and supports the lower back against the lumbar support of the chair. Standing up to move about every 30 to 60 minutes will loosen-up the back and legs.

Footstools can also make a difference when standing in one spot for prolonged periods. Placing one foot on a footstool or a phonebook reduces the curvature of the lower back alleviating muscle and spinal tension.

Feet can take a pounding over the course of a work day in the concrete-floored big box stores contributing to achy joints and back. Orthotics or cushion shoe inserts can act as a barrier to the unforgiving nature of concrete.

Sleep position plays a pivotal role in prevention. Placing one to two pillows under your knees while sleeping on your back will flatten your lower back against the mattress for better support. Similarly, when lying on your side, place a thick pillow between your upper thighs to prevent tilting of the pelvis. Lying on the stomach will increase the curvature of the lower spine and thus strain.

There are several common work-related injuries. Many people injure themselves by using one hand to quickly grab or lift an object. This sudden strain or stretch is akin to rapidly pulling on an elastic band. This rapid change exceeds the elastic’s ability to stretch and it snaps. Muscles respond in a similar vein. Slow deliberate movements instead of sudden jerky ones will prevent small tears within the muscle.

Lifting heavy objects from ground level requires a methodical and slow approach. Bend the knees and keep the back straight when lifting an object. Hold heavy objects close to the chest and slowly lift yourself up using your legs. Your lower back should not be bent at the waist in an attempt to pick up the object. Similarly avoid overstretching or straining to reach objects high up on a shelf.

Carrying infants and young children against the side of the hip can cause back injury should the child suddenly move. Back or front child carriers provide greater stability.

The cardinal rule for back care is to respect pain. If the back hurts, it is best to curtail the activity. For more information on back care: http://www.spine-health.com/, ,

© Dr. Barry Dworkin 2003

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