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Picture this, your new patient this afternoon is a runner with a history of a sacral stress fracture. She’s just received the results of a DEXA scan which revealed osteopenia. Running is really important to her. It lifts her mood and her social life revolves around it so she’s desperate to get back. How will you help her safely return to running and optimise her bone health?
Firstly in these situations, it’s important to consider why they have low bone mineral density (BMD). There are multiple considerations for this that need to be assessed and addressed (NOTE: The roles below will vary somewhat depending on local services so please see them as a rough guide):
Image inspired by Bone health and the masters runner by Raiser et al. (2024)
We developed a Bone Health Questionnaire as part of the clinic resources we provide in Running Repairs Online. It can help you identify some of these factors so they can be assessed in more detail. Use the link below to download your free copy.
Download your free Bone Health Questionnaire
A key consideration for runners with bone stress injuries is Relative Energy Deficiency in Sport (REDs). Relative energy deficiency is thought to occur when an athlete isn’t consuming enough to meet the energy demands of both sport and daily life. REDs affect multiple bodily systems including bone health, menstrual function, metabolism, sleep and cardiovascular and muscle function. As a result, it can impair health and performance and increase injury risk.
REDs is a complex topic that usually requires multidisciplinary management. For more on this see the recent IOC Consensus Statement – Mountjoy et al. (2023).
Tools have been developed to screen for REDs, including the recent IOC REDs CAT2 which includes a traffic light style system to guide return to sport. However, it does point out that, “The diagnosis of REDs is a medical diagnosis to be made by a sports medicine physician“.
Image: REDs Health Conceptual Model from Mountjoy et al. (2023)
A sensible first step if you’re working with a runner and you’re concerned about their bone health or energy availability is to contact their doctor/ GP.
You can share the results of the Bone Health Questionnaire with them and discuss your concerns. It also provides the opportunity to explore whether specialist input such as a referral to a sports medicine physician is indicated.
Some therapists or patients may prefer to refer directly to a sports med physician, especially if a more urgent opinion is needed. The key point here is to seek the right support for the patient. There are tests and investigations that we can’t provide for them and are necessary for their care so they need to see the right people within the multidisciplinary team.
Let’s examine some of these factors with this runner that’s seeing you for an appointment. Let’s call her Mel.
Relevant history
Mel is a 27-year-old female, she’s not pregnant and she reports a normal menstrual cycle. She has no other diagnosed medical history aside from the sacral stress fracture. Given her age and presentation, she’s unlikely to be perimenopausal (which could affect bone health).
Sacral stress fractures are a trabecular-rich site for bone stress injury. These often have greater associations with reduced energy availability, menstrual dysfunction and low BMD so we tend to investigate these factors in such injuries.
Mel has no relevant family history, she’s a non-smoker and drinks minimal alcohol.
Factors that may be managed by the GP
Mel is not taking any regular medication that might impact bone health (such as steroids or anticonvulsants). Her GP may arrange blood tests and advise on treatment options if Mel is low in Calcium, Vitamin D or Iron or has impaired thyroid function. When appropriate a GP can also prescribe medications to improve bone health such as bisphosphonates but they may not be indicated for Mel. For more on this topic Iqbal et al. (2019)
Factors that may be managed by a physio (or other therapist)
When we explore Mel’s previous training we discover it was high volume with a large percentage of high-intensity work and little recovery, this is likely to lead to fatigue and overload the bone. In order to fit this training around work Mel tends to run early in the morning and sacrifices sleep in order to do so. Sleep is thought to be important to bone health and lack of sleep may increase the risk of BSI.
At present Mel is not running so we would want to ensure that her energy availability and bone health needs have been met prior to planning a return. It would be sensible to plan this within a multidisciplinary team (considering the information below). Mel may be able to cross-train to maintain fitness and help mental wellbeing but she would need to ensure she fuels sufficiently to do this.
When Mel is ready to return to running we could advise Mel on her training structure and progression plus ensure recovery is planned into her weekly schedule and training blocks. Mel’s goal is to run a sub 3-hour marathon, for this it may be best to team up with a Running Coach for their input on optimising performance while training at a manageable level.
We would also assess Mel’s strength and conditioning needs and plan a programme with her to address them. This is likely to include progressive strengthening and plyometrics as both can improve bone health. These need to be introduced at the right stage of healing and carefully planned into the programme to prevent overload and fatigue.
Where specialist input may be needed
Mel tells us she uses a calorie-restricted diet alongside high-volume training to maintain a healthy weight (her BMI is 19). This may have resulted in energy deficiency which has impacted her bone health and may affect multiple health domains.
Mel mentions she’s been advised to reduce her running in the past but finds it very difficult to do so, instead her exercise has increased over time despite it causing conflicts with her partner. Mel also reports she’s very irritable and stressed when unable to exercise. These can be signs of exercise addiction or compulsion.
Considering these findings I would recommend a referral to a Sports Medicine Physician. They will assess Mel in further detail and evaluate the suspected REDs.
I would also suggest a referral to a Registered Dietician or Sports Nutritionist to ensure Mel’s energy and nutrition needs are being met.
There are screening tools that can be used for suspected exercise addiction but it may be sensible to refer to a mental health professional such as a Sports Psychologist who’s experienced in this area.
In summary, the following steps can be helpful when working with a runner with osteopenia or osteoporosis:
- Consider why they have low BMD – take a good history to identify these factors (and use the Bone Health Questionnaire)
- If bone health factors haven’t been addressed then discuss your concerns with the runner’s doctor/ GP including what specialist referrals and investigations may be indicated
- If treating an active bone stress injury then allow sufficient time for healing and aim to keep exercise pain-free
- Develop a rehab programme to address their needs and optimise bone health
- Set criteria for return to running to ensure they are both physically and psychologically ready for their sport
- Advise on training structure, progression and recovery to achieve their goals
- Monitor their response to keep them on track!
I appreciate this is a complex topic so for more information please see our module on Bone Stress Injuries in Running Repairs Online where we’ll guide you through the steps above in more detail.
