Treatment and Rehabilitation Approaches for Stress Fractures in Long-Distance Runners: A Literature Review

Stress fractures (SFs) result from repetitive mechanical stress on bones, leading to an imbalance in osseous tissue adaptation and resulting in cortical fractures. The majority of SFs occur in the lower limb due to excessive mechanical loads. Long-distance runners are highly susceptible to SFs, especially when there is a significant increase in the load or intensity of their activity. Various intrinsic and extrinsic factors contribute to the development of SFs. Common SF locations in long-distance runners include the tibial shaft, femur, metatarsal, and pelvic region. Diagnosis may be delayed due to mild symptoms and unremarkable imaging tests. However, the chronicity and recurrence of misdiagnosed SFs may lead to debilitating complete fractures that are even more challenging to treat. In this review, we present data revealed from published case reports and case series studies obtained through PubMed and Embase databases focusing on the management of SFs in long-distance runners and correlate treatment outcomes with rehabilitation and return to high-level athletic performance.

Neuromuscular activity of the lower-extremities during running, landing and changing-of-direction movements in individuals with anterior cruciate ligament reconstruction: a review of electromyographic studies

PURPOSE

Running, jumping/landing and cutting/change of direction (CoD) are critical components of return to sport (RTS) following anterior cruciate ligament reconstruction (ACLR), however the electromyographic (EMG) activity patterns of the operated leg during the execution of these tasks are not clear.

METHODS

A systematic review was conducted to retrieve EMG studies during running, jumping/landing and cutting/(CoD) in ACLR patients. MEDLINE, PubMed, SPORTDiscus and Web of Science databases were searched from 2000 to May, 2022 using a combination of keywords and their variations: "anterior cruciate ligament reconstruction" OR "ACLR", "electromyography" OR "EMG", "running", "jumping" OR "landing", "cutting" OR "change-of-direction" OR "CoD". The search identified studies comparing EMG data during running, landing and cutting/(CoD) between the involved limb and contralateral or control limbs. Risk of bias was assessed and quantitative analyses using effect sizes were performed.

RESULTS

Thirty two studies met the inclusion criteria. Seventy five percent (24/32) of the studies reported altered EMG activity pattern of the ACLR leg during running, jumping/landing and cutting/(CoD) when compared with either the healthy control leg or the contra-lateral leg. Twelve studies showed decreased, delayed or earlier onset and delayed peak in quadriceps EMG activity with small to large effect sizes and 9 studies showed increased, delayed or earlier onset and delayed peak in hamstrings EMG activity with small to large effect sizes. Four studies showed a "hamstrings-dominant" strategy i.e. decreased quadriceps coupled with increased hamstrings EMG activity in both running and jumping/landing irrespective of graft type. One study reported that on the grounds of decreased quadriceps activity, lower hamstrings EMG activity was predictive of ipsilateral re-injury in ACLR patients.

CONCLUSION

This systematic review of Level III evidence showed that the ACLR leg displays decreased quadriceps or increased hamstrings EMG activity or both despite RTS. Simultaneous decreased quadriceps and increased hamstrings EMG activity was shown for both running and jumping/landing. From a clinical perspective this "hamstrings dominant" strategy can serve as a protective mechanism against graft re-injury.

LEVEL OF EVIDENCE

III.