female marathon runner holding hip in pain

Dr John Rogers – Bone Stress Injuries – Injury Rehab Network

The July Injury Rehab Network with BASRaT featured a presentation from Dr John Rogers, Consultant Physician in Sport, Exercise and Musculoskeletal Medicine. The online event took place on the evening of Monday 7th July with 290 sports rehabilitation practitioners in attendance.

Dr Rogers discussed Bone Stress Injuries. The recording is available to watch here.

Dr John Rogers, Consultant Physician in Sport, Exercise and Musculoskeletal Medicine

Dr John Rogers is a Consultant Sport and Exercise Medicine (SEM) Physician who specialises in Orthopaedic / Musculoskeletal problems and Concussion. His work also involves treating people with medical problems related to physical activity e.g. overtraining syndrome / fatigue and underperformance, cardiac and respiratory problems with exercise, vascular disease related to sport, mental health problems in athletes, and various nutritional deficiencies such as Relative Energy Deficiency in Sport (REDs).

In clinical practice, his work involves close collaboration with a multidisciplinary team of radiology, medical and surgical consultants, physiotherapists, and sports science colleagues to coordinate patient care.

John works as a Visiting Professor at Manchester Metropolitan University, leading the team physician module of the MSc course in SEM. He served as Training Programme Director for SEM in NW England from 2019 to 2022, overseeing regional training for junior doctors for SEM. Previous roles include Chief Medical Officer to British Triathlon, Institute Medical Officer to British Athletics, Consultant SEM Physician at the Defence Military Rehabilitation Centre, Headley Court, and Chief Medical Officer to Team GB at the Youth Olympic Games.

His interest in sport and exercise began early in life. A competitive middle-distance runner with Sale Harriers Manchester, he also won Northern Ireland senior titles over 800 and 1500 metres during that period. He continues to enjoy running and cycling and doing various other sports with his three children.

Bone Stress Injuries

Xray of bone injury

During the presentation, Rogers discussed the diagnosis and management of bone stress injuries. He provided an introduction to his role as Sport and Exercise Medicine Consultant at the OrthTeam Centre, Visiting Professor at Manchester Metropolitan University, and Team Physician for British Athletics and the London Marathon.

He highlighted the ‘dreaded black line’, referring to fractures identified on x-rays. Stress fractures are commonly seen in the lumbar spine, pelvis, and lower limb. Learning objectives were outlined as:

Understand the pathogenesis
Describe risk factors
Discuss how to make a diagnosis
Discuss the management of stress fractures
Describe key aspects of prevention
Case discussion

Wolff’s Law

Julius Wolff (1839–1902) identified bone as a dynamic tissue, constantly altering its shape, strength, and density in response to external forces. The importance of bone health was emphasised, particularly the balance between microfracture and repair, and the overall process of bone remodelling.

Stress Fractures

A stress fracture was defined as “a partial or complete bone fracture that results from repeated application of a stress lower than the stress required in order to fracture the bone in a single loading.” Rogers explained a continuum of bone stress injuries, ranging from remodelling through to stress reaction, which may progress to a full stress fracture.

Groups at risk include:

Track and field athletes
Endurance athletes
Military personnel
Dancers
Gymnasts
Team sports athletes (football)

Practitioners were advised to investigate further when athletes are involved in sports with low thresholds for injury, when high-risk sites are suspected, or when red flags are present. High-risk sites, particularly in the lower limb, heal slowly, are prone to complications, and often require surgery.

Risk factors considered included excessive load/rapid progression, biomechanical issues, vitamin D deficiency, muscle weakness, and female athlete triad/RED-S. Stress fractures are more common in female athletes who do not have periods, while sports such as fast cricket bowling and long-distance running carry a higher risk.

Energy deficiency in sports that emphasise leanness, such as gymnastics, dance, and cycling, was also discussed. Relative Energy Deficiency in Sport (RED-S) affects bone health, and studies show higher rates of eating disorders in athletes. Rogers recommended resources such as BEAT, Health for Performance, and Project RED-S for support.

Pain patterns, location, timing, rest or night pain, and aggravating/relieving factors were highlighted as key indicators for further investigation.

Examination and Scans

When assessing patients, Rogers considers both history and recent changes in training load, intensity, type of training, and equipment used.

Examination includes focal tenderness, hopping, fulcrum test, extension with rotation, and the stork test. If pain is present on impact, a stress fracture is likely. Any positive tests warrant further investigation with MRI scans, which Rogers described as the best diagnostic tool for stress fractures. CT scans may also be useful to identify high-risk fractures and guide management when time is limited.

Stress Fracture Management

Optimal management strategies were described as:

Pain control – avoid NSAIDs
Offload/activity modification
Maintain aerobic fitness
Identify and modify risk factors
Return to sport/activity
Multidisciplinary Team decision

John considered ways to maintain fitness in elite athletes with stress fractures, with options to offload and modify activities. Pool-based activities such as swimming, deep water running, and aqua jogging are effective. Cycling is a good outside activity, and gym-based activities, including rowing and cross trainers, are also effective ways to maintain fitness.

For lower leg injuries (tibia), John described that pneumatic bracing (boots) are shown to reduce time to return to full activity.

The risks and negative effects of NSAIDs were considered in relation to the management and healing of stress fractures. NSAIDs slow or prevent repair and should be avoided.

Parathyroid Hormone injections were discussed, which have an anabolic effect on bone and stimulate bone formation. John also discussed the use of Bisphosphonate Injections, which can be considered as a treatment option when the patient has pain and is unresponsive to usual management options. Bisphosphonate injections may be regarded as in time-critical performance situations. Still, the risks should be managed, including avoiding conception for 6 months post, monitoring renal function, risk of osteonecrosis and avoiding use in low bone turnover states (RED-S).

Stress Fracture Prevention

Dr Rogers considered strategies for the prevention of bone stress injuries including:

Education – training intensity, volume, frequency
Address strength deficits/ kinetic chain issues
Biomechanical assessment
Energy balance – senr.org.uk
Vitamin D supplementation
Calcium – 1200mg daily
DEXA data

Case Study – Elite Marathon Runner

A case study was presented of an elite marathon runner with a stress fracture 5 days before an international race. The athlete had pain in their left anterior hip with a gradual onset during a session. Pain was worse during a long run of over 90 minutes. They had suffered a bone stress injury to the tibia previously.

On examination, the athlete had a full range of movement to the left hip with pain at the end range. The FADIR test was positive, and the athlete resisted hip flexion.

The athlete and their team were left with a difficult decision, but following a detailed discussion of the risks, decided to race the marathon. After the race, the athlete finished in severe pain and required Penthrox and crutches.

Further management of the injury included partial weight bearing on crutches for 4 weeks and cross training after 2 weeks. Blood screening was completed to assess for RED-S, and the athlete increased their intake of Vitamin D and Calcium. Support was provided for sports nutrition, and the physio/ S&C team led rehab. A CT scan was completed at 8 weeks to assess the injury site.

Summary

The presentation concluded with a recap of pathogenesis, risk factors, diagnosis, management, and prevention of stress fractures. He described the importance of a good multidisciplinary team (MDT) and the various practitioners that may support athletes with stress fractures, including:

Sports physician
Physiotherapist
Orthopaedic Surgeon
Nutritionist
Strength & Conditioning Coach
Psychologist
Metabolic Bone Physician
Biomechanist
Radiologist

Further information and follow Dr John Rogers

Dr John Rogers OrthTeam Centre

Q&A

Questions from practitioners were answered during the live session. See the recording for details.

Presentation Recording

The recording of John’s presentation is available to watch here.

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