Thursday, 8 December 2011

Stress? Fracture.

The New York City Marathon took place on Sunday, November 5, 2006. More than 35,000 runners from all corners of the Earth participated. Thousands of spectators cheered them on. Even Lance Armstrong ran the race this year.

What this means for me as a cyclist is that, after having retired my running shoes after last year's race, I joined some of my cycling mates to marshal the race for wheelchair and handicapped athletes. Marathon Day is possibly the best day of the year in New York City. The positive energy is overwhelming

What this means for me as an orthopedist is that many runners in the marathon come to the office for myraid aches, sprains, pains, twists, cracks and clicks. Most of these issues are benign; they can be treated with rest, cross-training and over the counter medicines.

Some of them are not.

Our bones are made to withstand the forces of our activity. They are remarkable in this quality. They do this through their material properties of strength and elasticity. That is, they either resist the forces or bend to accommodate them. Until they don't.

Fractures occur when the force on a structure exceeds its material properties. Sometimes this happens because the force is too great; a car accident or a fall from a height. In other cases, the material properties of the bone are changed; there is a metabolic disease or age-related change to the bones so that they aren't able to stand up to everyday stresses. Something so simple as stepping from a curb might cause a break.

Finally, there are "overuse injuries." The stresses themselves aren't enough to overwhelm the properties of the bone. But, cumulatively, relentless sub-threshold stresses can cause failure of the bone structure. When we place great, but not failure-level forces across our bones repeatedly, a "stress fracture" can occur.

A person with a stress fracture may have normal xrays. She may only have pain when she does high-impact activity. She may have enough pain to cause her to go to see a doctor. Sometimes the fracture is never detected and the person self-limits because of pain, the fracture heals and life goes on. If symptoms cause concern, an MRI test or a bone scan can detect the injury and treatment can be rendered. However, if the offending activites continue, the bone could snap and require surgery or some other "drastic" measure.

Now our bones are governed by our physiology. Unless there is something wrong with our healing process, bones will mend when treated appropriately.

But what happens when we overwhelm other systems? How do we deal with the relentless sub-threshold stresses on our emotional skeleton? There's nothing so definitive as an MRI test to tell us when we've reached the limits of our patience. The pains related to stress fractures of this nature are vague and difficult to localize.

I've treated four patients in the past 6 weeks with real stress fractures of their bones. One woman had fractures in both hips. Another, in her foot. A young boy had a break in his tibia. Another young lady was unlucky enough to have had a stress fracture which cracked completely and required surgery. All of these folks were under 33 years old.

In contrast, I cannot count the number of patients, mostly young women with small children, who come in for treatment of low back pain, neck pain, hand pain, knee pain, shoulder pain... the list goes on. These women seldom have a concrete medical problem. I believe the issues here are with the taxing of other systems. Many of my such patients sleep only three or four hours per night because of work, house and child care duties. Some have not had a day to themselves for years. They are exhausted, stressed and overwhelmed and this shows up in the form of physical pains.

But how do I treat this? My tool kit includes medicines, therapy and surgery. Is there a way to fortify people so that they are more resilient? Or do we just wait for them to break?

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