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.

The topic was 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

The presentation covered the diagnosis and management of bone stress injuries. It included 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 referred to the ‘dreaded black line’, describing fractures identified on x-rays. Stress fractures are commonly seen in the lumbar spine, pelvis, and lower limb.

Learning objectives:

1. Understand the pathogenesis
2. Describe risk factors
3. Discuss how to make a diagnosis
4. Discuss management of stress fractures
5. Describe key aspects of prevention
6. 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 lies in maintaining homeostasis between microfracture and repair, and in the 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.”

A continuum of bone stress injuries was presented, from remodelling through to stress reaction which may lead to stress fracture.

Groups at risk include:

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

When to investigate depends on the sport, threshold, high-risk sites, level/intensity of competition, risk factors, and red flags. High-risk sites are mainly in the lower limb, do not heal quickly, are prone to complications, and often require surgery.

Risk factors include excessive load or rapid progression, biomechanical issues, vitamin D deficiency, muscle weakness, and female athlete triad/RED-S. Stress fractures are more common in female athletes without regular periods. Certain sports such as cricket fast bowling and long-distance running carry higher risk.

Energy deficiency is common in sports that emphasise leanness, such as gymnastics, dance, and cycling. Relative Energy Deficiency in Sport (RED-S) has multiple effects, including risks to bone health. Studies show athletes have a higher incidence of eating disorders. Recommended support is available from BEAT, Health for Performance, and Project RED-S.

Pain can be an indicator of stress fractures. Location, timing, rest or night pain, and aggravating or relieving factors should prompt further investigation.

Examination and Scans

Assessment should include patient and training history: changes in training volume, intensity, type, other activities, and equipment/clothing used.

Examination of athletes includes focal tenderness, hopping, fulcrum test, extension with rotation, and the stork test. Pain and pain on impact suggest a stress fracture. Positive tests should be followed by MRI scans, considered the best diagnostic tool. CT scans are also used for identifying high-risk fractures and supporting management decisions under time pressure.

Injuries evolve over time, and progression can lag behind symptoms.

Stress Fracture Management

Optimal management includes:

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

Ways to maintain fitness in elite athletes with stress fractures include pool-based activities (swimming, deep water running, aqua jogging), cycling, and gym-based activities such as rowing and cross trainers.

For tibial injuries, pneumatic bracing (boots) can reduce time to return to full activity.

NSAIDs should be avoided as they slow or prevent repair.

Parathyroid Hormone injections may stimulate bone formation. Bisphosphonate injections can be considered when pain persists despite standard management, but carry risks including delayed conception, renal monitoring, risk of osteonecrosis, and contraindications in low bone turnover states (RED-S).

Stress Fracture Prevention

Prevention strategies include:

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

Case Study – Elite Marathon Runner

John presented a case study of an elite marathon runner with a stress fracture 5 days ahead of a race. The athlete had pain in their left anterior hip with 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 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. The athlete finished in severe pain and required Penthrox and crutches following the race.

The 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 key points on stress fractures covered pathogenesis, risk factors, diagnosis, management, and prevention. The importance of a good multidisciplinary team (MDT) was highlighted, including:

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

Further information and follow Dr John Rogers

OrthTeam Centre

Q&A

Questions from practitioners were answered during the session. Please see the recording of the presentation for these insights.

Presentation Recording

The recording of the presentation is available here.

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