Emily Kraus, MD

Abstract

BACKGROUND: Tarsal navicular bone stress injuries (BSIs) are considered "high risk" because of prolonged healing times and higher rates of nonunion in adult populations but, to our knowledge, have not been comprehensively examined in adolescent athletes.PURPOSE: To describe the characteristics of tarsal navicular BSIs in adolescents.STUDY DESIGN: Case series; Level of evidence, 4.METHODS: A retrospective analysis of patients aged 10 to 19 years with a radiographically diagnosed tarsal navicular BSI was performed at 8 academic centers over a 9-year study period. Age, sex, body mass index (BMI), primary sport, physical examination findings, imaging, treatment, surgical technique, return-to-sport time, and complications were analyzed.RESULTS: Among 110 patients (mean age, 14.7 2.7 years; 65% female), common primary sports were cross-country/track and field (29/92 [32%]) and gymnastics/dance (25/92 [27%]). Grade 4 BSIs were identified in 44% (48/110) of patients, with fracture lines present on radiography or magnetic resonance imaging. Nonoperative treatment (mean age, 14.4 2.6 years), consisting of protected weightbearing and either a protective boot (69/88 [78%]) or a cast (19/88 [22%]), was trialed in all patients and was successful in 94 patients (85%). Operative treatment (mean age, 17.1 1.4 years) was ultimately pursued for 16 patients (15%). Patients who required surgery had a higher BMI and a higher percentage of fracture lines present on imaging (nonoperative: 36/94 [38%]; operative: 14/16 [88%]). The median time to return to weightbearing, running, and full sport was significantly longer in duration for the operative group than the nonoperative group (P <.05). Complications associated with surgery included 1 case each of delayed union, nonunion, and painful implants, the latter of which required secondary surgery.CONCLUSION: Adolescent tarsal navicular BSIs were identified most commonly in female patients in leanness sports. Adolescents who required surgery were more likely to be older, have higher BMIs, and have grade 4 BSIs, and they returned to sport within a median of 5 months after single- or double-screw fixation with a low risk of postoperative complications. A better understanding of the presenting signs and symptoms and appropriate diagnostic imaging of navicular BSIs may lead to an earlier diagnosis and improved outcomes.

View details for DOI 10.1177/03635465231170399

View details for PubMedID 37265102

Abstract

For adults, increasing cadence reduces ground reaction forces, but a lower preferred cadence does not predispose adults to experience higher ground reaction forces. Pubertal growth and motor control changes influence running mechanics, but it is unknown if preferred cadence or step length are associated with ground reaction forces for pre-adolescent and adolescent runners. Pre-adolescent and adolescent runners underwent an overground running analysis at a self-selected speed. Mixed model multiple linear regressions investigated the associations of preferred cadence, step length, physical maturation, and sex on ground reaction forces, while accounting for running speed and leg length. Running with a lower preferred cadence or longer preferred step length was associated with larger peak braking and vertical forces (p.01), being less physically mature was associated with larger vertical impact peak force and vertical loading rate (p.01), and being a male was associated with larger loading rates (p.01). A lower preferred cadence or longer preferred step length were associated with higher braking and vertical forces and being less physically mature or a male were associated with higher loading rates. An intervention to increase cadence/decrease step length could be considered if ground reaction forces are a concern for an adolescent runner.

View details for DOI 10.1080/14763141.2023.2218325

View details for PubMedID 37246741

Abstract

Runners and coaches are often interested in identifying the "ideal" running form to reduce the risk of injury and improve performance. While differences in pelvis and hip motion have been reported among adolescent female and male long-distance runners of different stages of physical maturation, the influence of sex and/or maturation on temporal-spatial parameters is unknown for adolescent runners. Adolescent runners of different stages of physical maturation (pre-, mid-, post-pubertal) completed an overground running analysis at a self-selected speed. We performed 2*3 ANCOVAs (covariate=running speed) to compare temporal-spatial parameters among sex and maturation groups. Pre-adolescents ran with higher cadences and shorter step lengths than mid- (p .01) and post-pubertal adolescents (p .01), respectively. Mid-pubertal males and post-pubertal females also ran with higher cadences and shorter step lengths than post-pubertal males (p .01). When step length was normalized to leg length, less physically mature runners demonstrated longer normalized step lengths (p .01). Caution is advised when using a "one-size-fits-all" approach for recommending an "ideal" cadence and/or step length for adolescent long-distance runners. A runner's sex, stage of physical maturation and leg length should be considered when assessing and prescribing cadence and/or step length.

View details for DOI 10.1080/02640414.2022.2142743

View details for PubMedID 36352559

Abstract

BACKGROUND: Limb asymmetry after ACL reconstruction is often cited as a risk factor for ACL reinjury. We assessed ground reaction forces on each limb during a drop vertical jump, and compared kinetic symmetry between limbs in adolescents post-ACL reconstruction versus healthy controls.METHODS: Forty-four participants who underwent an ACL reconstruction (16 male/28 female, mean age 16.11.5, mean 7.30.9months post-ACL reconstruction) and 34 controls (20 male/14 female, mean age 14.91.1) completed a drop vertical jump captured on a Vicon system and Bertec force plates. Kinetic variables were calculated individually for each limb. Inter-limb asymmetry was calculated as an index between each limb (involved versus uninvolved for the ACL reconstruction group, and left versus right for controls), and was compared between groups using independent t-tests.FINDINGS: Asymmetry was significantly more pronounced in the ACL reconstruction group versus the controls for peak contact ground reaction force (11.6% vs 4.4%, p=0.009), eccentric impulse (8.8% vs 3.8%, p=0.009), eccentric mean force (8.0% vs 3.4%, p=0.006), concentric peak ground reaction force (4.1% vs 0.8%, p=0.003), concentric impulse (5.1% vs 1.1%, p=0.001), and peak landing ground reaction force (12.7% vs 1.7%, p<0.001).INTERPRETATION: Limb kinetic asymmetry during a drop vertical jump was more pronounced in adolescents post-ACL reconstruction versus controls for both eccentric- and concentric-phase variables, which may indicate the use of compensatory strategies to offload the post-operative limb. Targeted interventions to produce more symmetric loading and unloading during jumping tasks should be developed, tested, and monitored to determine the impact on rehabilitation programs, return-to-sport evaluations, and injury prevention outcomes.

View details for DOI 10.1016/j.clinbiomech.2022.105794

View details for PubMedID 36270179

Abstract

Stress injuries to the bone and physis of the knee are common in the active adolescent patient and can be broken down into bone stress injuries (BSIs) and chronic physeal stress injuries. BSIs result from prolonged, repetitive bone loading, whereas chronic physeal stress injuries develop from repetitive loading to the apophysis or epiphysis. Most stress injuries of the knee resolve with relative rest but will occasionally need surgical intervention in more severe cases. Early and accurate identification is paramount for optimal management and to avoid long-term consequences.

View details for DOI 10.1016/j.csm.2022.05.008

View details for PubMedID 36210167

View details for Web of Science ID 000888056602469

View details for Web of Science ID 000888056602275

Abstract

Background: Bone stress injury (BSI) is a common reason for missed practices and competitions in elite track and field runners.Hypothesis: It was hypothesized that, after accounting for medical risk factors, higher plantar loading during running, walking, and athletic movements would predict the risk of future BSI in elite collegiate runners.Study Design: Cohort study; Level of evidence, 2.Methods: A total of 39 elite collegiate runners (24 male, 15 female) were evaluated during the 2014-2015 academic year to determine the degree to which plantar pressure data and medical history (including Female and Male Athlete Triad risk factors) could predict subsequent BSI. Runners completed athletic movements while plantar pressures and contact areas in 7 key areas of the foot were recorded, and the measurements were reported overall and by specific foot area. Regression models were constructed to determine factors related to incident BSI.Results: Twenty-one runners (12 male, 9 female) sustained 1 incident BSI during the study period. Four regression models incorporating both plantar pressure measurements and medical risk factors were able to predict the subsequent occurrence of (A) BSIs in female runners, (B) BSIs in male runners, (C) multiple BSIs in either male or female runners, and (D) foot BSIs in female runners. Model A used maximum mean pressure (MMP) under the first metatarsal during a jump takeoff and only misclassified 1 female with no BSI. Model B used increased impulses under the hindfoot and second through fifth distal metatarsals while walking, and under the lesser toes during a cutting task, correctly categorizing 83.3% of male runners. Model C used higher medial midfoot peak pressure during a shuttle run and triad cumulative risk scores and correctly categorized 93.3% of runners who did not incur multiple BSIs and 66.7% of those who did. Model D included lower hindfoot impulses in the shuttle run and higher first metatarsal MMP during treadmill walking to correctly predict the subsequent occurrence of a foot BSI for 75% of women and 100% without.Conclusion: The models collectively suggested that higher plantar pressure may contribute to risk for BSI.

View details for DOI 10.1177/23259671221104793

View details for PubMedID 35734769

View details for DOI 10.1007/s40141-021-00326-3

View details for Web of Science ID 000702215900001

View details for Web of Science ID 000693128400450

Abstract

INTRODUCTION: Bone stress injury (BSI) in youth runners are clinically important during times of skeletal growth and are not well studied.OBJECTIVE: Evaluate the prevalence, anatomical distribution, and factors associated with running-related BSI in boy and girl middle school runners.DESIGN: Retrospective cross-sectional study.SETTING: Online survey distributed to middle school runners.METHODS: Survey evaluated BSI history, age, grade, height, weight, eating behaviors, menstrual function, exercise training, and other health characteristics.MAIN OUTCOME MEASUREMENTS: Prevalence and characteristics associated with history of BSI, stratified by cortical-rich (eg, tibia) and trabecular-rich (pelvis and femoral neck) locations.PARTICIPANTS: 2107 runners (n=1250 boys, n=857 girls), age 13.20.9y.RESULTS: One hundred-five (4.7%) runners reported a history of 132 BSIs, with higher prevalence in girls than boys (6.7% vs 3.8%, P=0.004). The most common location was the tibia (n=51). Most trabecular-rich BSIs (n=16, 94% total) were sustained by girls (pelvis: n=6; femoral neck: n=6; sacrum: n=4). In girls, consuming <3 daily meals (OR=18.5, 95%CI=7.3, 47.4), eating disorder (9.8, 95%CI=2.0, 47.0), family history of osteoporosis (OR=6.9, 95%CI=2.6, 18.0), and age (OR=1.6, 95%CI=1.0, 2.6) were associated with BSI. In boys, family history of osteoporosis (OR=3.2, 95%CI=1.2, 8.4), prior non-BSI fracture (OR=3.2, 95%CI=1.6, 6.7), and running mileage (OR=1.1, 95%CI=1.0, 1.1) were associated with BSI. Participating in soccer or basketball 2years was associated with lower odds of BSI for both sexes.CONCLUSION: While family history of osteoporosis and prior fracture (non-BSI) were most strongly related to BSI in the youth runners, behaviors contributing to an energy deficit, such as eating disorder and consuming<3 meals daily, also emerged as independent factors associated with BSI. While cross-sectional design limits determining causality, our findings suggest promoting optimal skeletal health through nutrition and participation in other sports including soccer and basketball may address factors associated with BSI in this population. This article is protected by copyright. All rights reserved.

View details for DOI 10.1002/pmrj.12673

View details for PubMedID 34251763

Abstract

PURPOSE OF REVIEW: This review article seeks to highlight common youth athlete knee conditions due to overuse or trauma and elucidate differences from the adult populations.RECENT FINDINGS: Overuse conditions presented include apophysitis, osteochondritis dissecans plica syndrome, and discoid meniscus. Traumatic conditions presented include patellar instability, patellar sleeve fracture, and patellofemoral osteochondral fractures. Knee injuries affect a significant proportion of youth athletes. These injuries place athletes at higher risk of chronic pain and potentially osteoarthritis. We have reviewed common overuse and traumatic knee injuries and differentiating factors between the adult population to improve and expedite the diagnosis, treatment, and prognosis for youth athletes with knee injuries.

View details for DOI 10.1007/s12178-021-09708-5

View details for PubMedID 33818701

Abstract

Barrack, MT, Fredericson, M, Dizon, F, Tenforde, AS, Kim, BY, Kraus, E, Kussman, A, Singh, S, and Nattiv, A. Dietary supplement use according to sex and Triad risk factors in collegiate endurance runners. J Strength Cond Res XX(X): 000-000, 2020-This cross-sectional study evaluated the prevalence in the use of dietary supplements among elite collegiate runners among 2 NCAA Division I cross-country teams. At the start of each season from 2015 to 2017, male and female endurance runners were recruited to complete baseline study measures; the final sample included 135 (male n = 65, female n = 70) runners. Runners completed a health survey, web-based nutrition survey, and Triad risk assessment. The prevalence of dietary supplement use and Triad risk factors, including disordered eating, low bone mass, amenorrhea (in women), low body mass index, and stress fracture history, was assessed. A total of 78.5% (n = 106) runners reported taking 1 or more supplements on 4 days per week over the past month, 48% (n = 65) reported use of 3 supplements. Products used with highest frequency included multivitamin/minerals 46.7% (n = 63), iron 46.7% (n = 63), vitamin D 34.1% (n = 46), and calcium 33.3% (n = 45). More women, compared with men, used iron (61.4 vs. 30.8%, p < 0.001) and calcium (41.4 vs. 24.6%, p = 0.04); men exhibited higher use of amino acids and beta-alanine (6.2 vs. 0%, p = 0.04). Runners with bone stress injury (BSI) history, vs. no previous BSI, reported more frequent use of 3 supplements (61.5 vs. 32.8%, p = 0.001), vitamin D (49.2 vs. 19.4%, p < 0.001), and calcium (47.7 vs. 19.4%, p = 0.001). Low bone mineral density was also associated with higher use of vitamin D and calcium. Most runners reported regular use of 1 or more supplements, with patterns of use varying based on sex, history of BSI, and bone mass.

View details for DOI 10.1519/JSC.0000000000003848

View details for PubMedID 33278271

View details for Web of Science ID 000590026300193

View details for Web of Science ID 000590026300006

View details for Web of Science ID 000590026303111

View details for Web of Science ID 000590026303200

View details for Web of Science ID 000590026302610

View details for Web of Science ID 000590026301707

Abstract

The health benefits of regular recreational physical activity are well known in reducing secondary health consequences of a sedentary lifestyle in the general population. However, individuals with physical disabilities participate less frequently in recreational activity compared with those without disabilities. Although evidence on the impact of recreational physical activity on quality of life in this population is in its infancy, regular recreational and sports activity participation has shown to have a positive association with improvements in quality of life, life satisfaction, community reintegration, mood, and employment in those with disabilities. Facilitators of participating in adaptive sports include a desire to improve social support, physical fitness, health, and fun. Unfortunately, those with disabilities face numerous barriers to participate in adaptive sports including accessibility, transportation, awareness, finances, and physical and cognitive impairments. Further studies are needed to investigate facilitators and barriers to participating in adaptive sports to capitalize on the physical and psychosocial benefits of regular recreational activity. The aim of this article is to review the available literature on the effects of adaptive sports participation on quality of life.

View details for DOI 10.1097/JSA.0000000000000242

View details for PubMedID 31046012

View details for PubMedID 30442429

View details for Web of Science ID 000456870500261

Abstract

Bone stress injuries are common in military personnel and athletes. The delayed diagnosis of a bone stress injury can lead to a more severe injury that requires a longer period of treatment. The early detection of bone stress injuries is a central part of management. Currently, the reference standard for detecting bone stress injuries is magnetic resonance imaging. However, the expanding use of point-of-care ultrasonography (US) may enable the early detection of bone stress injuries in the clinical setting. In this article, we review the US detection of bone stress injuries, as well as discuss the rationale for the use of US in the diagnosis of these injuries.

View details for PubMedID 29655254

View details for DOI 10.1249/01.mss.0000519298.55627.5d

View details for Web of Science ID 000415216000102

View details for DOI 10.1249/01.mss.0000520026.24336.5f

View details for Web of Science ID 000415216000792

Abstract

Student-run free clinics (SRFCs) have emerged as an important educational component of United States (US) medical schools. Despite the prevalence of musculoskeletal (MSK) problems presenting to SRFCs, students and clinics are often unprepared to diagnose and to treat common MSK complaints.We sought to determine the scope of diagnosis and treatment at a medical student-run free clinic specializing in musculoskeletal care using physical medicine and rehabilitation (PM&R) residents. Secondary goals included reviewing student satisfaction and determining the appropriateness of the clinic in medical education.Retrospective chart review, anonymous online survey.Primary care, free student clinic affiliated with tertiary academic medical center.A total of 20 medical student volunteers, 6 PM&R residents, and 91 community patients.We established a musculoskeletal clinic as a specialty referral clinic for the 2 primary care SRFCs with institutional support from a partner medical school. We then reviewed clinical operations retrospectively using electronic medical records and student satisfaction based on an online survey.We analyzed patient demographics and chief complaints, referrals provided, and medical services rendered. We also used a 5-point Likert scale to assess student satisfaction.A monthly musculoskeletal referral clinic was established with the oversight of PM&R attendings and residents. The clinic received 91 referrals and managed 61 unique patients over a 2.5-year study period. The most common presentations to the clinic involved knee pain (n = 17, 27.9%) and back pain (n = 16, 26.2%). Pro bono relationships with community and institutional partners enabled all patients to receive medical examinations, physical therapy visits, plain film radiographs, and insurance consultations free of charge. Student satisfaction with teaching and patient care was high, with 19 of 20 students reporting their experience as "good" or "excellent."SRFCs represent an underused opportunity to enhance MSK education among medical students by treating a variety of common MSK complaints in an underserved population.To be determined.

View details for DOI 10.1016/j.pmrj.2017.03.008

View details for PubMedID 28389399

View details for DOI 10.1016/j.pmrj.2016.07.196

View details for PubMedID 27672919

Abstract

A 68-year-old male long distance runner presented with low back and left buttock pain, which eventually progressed to severe and debilitating pain, intermittently radiating to the posterior thigh and foot. A comprehensive workup ruled out possible spine or hip causes of his symptoms. A pelvic magnetic resonance imaging neurogram with complex oblique planes through the piriformis demonstrated variant anatomy of the left sciatic nerve consistent with the clinical diagnosis of piriformis syndrome. The patient ultimately underwent neurolysis with release of the sciatic nerve and partial resection of the piriformis muscle. After surgery the patient reported significant pain reduction and resumed running 3 months later. Piriformis syndrome is uncommon but should be considered in the differential diagnosis for buttock pain. Advanced imaging was essential to guide management.

View details for DOI 10.1016/j.pmrj.2015.09.005

View details for PubMedID 26377629

Abstract

Bone stress injuries (BSIs) are common running injuries and may occur at a rate of 20% annually. Both biological and biomechanical risk factors contribute to BSI. Evaluation of a runner with suspected BSI includes completing an appropriate history and physical examination. MRI grading classification for BSI has been proposed and may guide return to play. Management includes activity modification, optimizing nutrition, and addressing risk factors, including the female athlete triad. BSI prevention strategies include screening for risk factors during preparticipation evaluations, optimizing nutrition (including adequate caloric intake, calcium, and vitamin D), and promoting ball sports during childhood and adolescence.

View details for DOI 10.1016/j.pmr.2015.08.008

View details for PubMedID 26616181