URMC Orthopaedics

and Rehabilitation

Epidemiology, Diagnosis and

Management of the Female Athlete

Triad Katie Rizzone MD MPH

Assistant Professor of Orthopaedics and

Rehabilitation and Pediatrics

Team Physician, The College at Brockport and the

University of Rochester

Medical Director, Athletic Training Education Program, The

College at Brockport

I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services

Disclosures

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Objectives

• Review etiology of stress fractures

• Review diagnostic imaging for pathology

• Discuss management options

• Discuss return to play guidelines

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Peak Bone Mass

• 90% of peak bone mass is formed by age 18

What Controls Bone Health?

• Bone remodeling is constant

• Balance between breaking down and building back up – Hormones

– Age

– Diet

– Medications

– Activity

What Controls Bone Health?

• Bone remodeling is constant

• Balance between breaking down and building back up – Hormones: sex, calciotrophic

– Age: balance shifts with increasing age

– Diet: Ca, Vit D, PO4

– Medications: antacids, PPI’s, SSRI, GC

– Activity: weight-bearing, muscle contracture, BMI

What is a Stress Fracture?

• Microfracture of a bone from repetitive stress

Epidemiology of Stress Fractures

• Females >> Males

• Common locations:

– Metatarsals

– Tibia

– Fibula

• Sport dependent

– Track vs baseball vs rowing

Known Risks for Stress Fractures

• Hormonal imbalance

• Poor dietary intake of bone building/stabilizing nutrients

• Previous stress fractures

• Gender

• Race

Female Athlete Triad

Dr. Rizzone’s Triad

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Energy Availability

Bone Health

Hormone Balance

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EA and Hormones

• If you don’t eat enough

– Decr GnRH

• Decr estrogen and testosterone

• Trying to save energy

– Decr Thyroid hormones

Hormones and Stress Fractures

• Sex hormones control bone remodeling through osteoclasts and osteoblasts

• osteoclast activity

Hormones and Stress Fractures

estrogen and testosterone

bone turnover

Take a good menstrual history

• Menarche

• Amenorrhea/Oligomenorrhea

On birth control? OCP’s, shot, IUD

Diagnosis

• Clinical

• Imaging

Diagnosis

• Clinical:

– History

– Exam

• Imaging: – X-ray

– MRI

– Bone scan

– Ultrasound

Diagnosis

• Clinical

– History: mileage, changes in exercise level

– Exam: pain over specific spot

Diagnosis

• Clinical: History and exam

• Imaging – X-ray

• 10% sensitivity initially but 30-70% after 3 weeks

– MRI: high sens and high specificity

– Bone scan: 74-100% sens but less spec than MRI

– Ultrasound: ? Future ?

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Reaction vs. Fracture

Stress reaction

• Periosteal or marrow edema without fracture line

Stress fracture

• Periosteal or marrow edema with fracture line

Grades of Injuries

• I = isolated periosteal edema

• II = T2 increased marrow signal, T1 normal

• III = T2 increased signal in marrow, T1 decreased signal

• IV = fracture line with surrounding marrow edema

T1 versus T2

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High Risk Stress Fractures

Tension, poor vascularity or have serious negative outcomes if undertreated • Femoral neck • Patella • Anterior tibial shaft • Medial malleolus • Navicular • 5th metatarsal base • Proximal 2nd metatarsal • Sesamoids

High Risk Stress Fracture

• Non-weight bearing

• Consider surgical therapy

• Need evidence of healing on x-ray before starting back to a graded return to play

Medium Risk Stress Fractures

• Pelvis

• Femoral shaft

• Proximal tibia

• Cuboid

• Cuneiform

Medium Risk Stress Fracture

• Immobilize

• Can do pain-free activity

Low Risk Stress Fracture

• Posteromedial tibia

• Fibula

• Calcaneus

• Distal metatarsals 2-5

Low Risk Stress Fractures

• Immobilize if pain with ambulation

• Pain-free activity

Laboratory Work-up

What?

• CBC

• CMP

• Vit D

• PTH

• TSH

• Mg

• Urine labs

Who?

• Recurrent stress injuries

• Trabecular fractures: femoral neck, sacrum, pelvis

• Fractures with low trauma

Recovery

Energy Availability

• Ask about food sources

– Restrictive diets (lactose, gluten, veg/vegan)

– Food diaries

• Review Ca and Vit D levels

• OCP’s do NOT normalize the system

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Calcium and Vitamin D

Treatment for low EA

**Fix the imbalance**

• Increase intake

• Decrease energy needs

Treatment for abnormal menses

• *Pregnancy test

• Treat low EA

• Rare: work-up for metabolic disease

• Rare: work-up for other hormonal issues

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Treatment for bone abnormalities

• Treat low EA

• Supplementation

• NSAIDS: ?

• Biphosphanates?

• OCP’s?

• Bone stimulation

Other factors

• Review gait

• Shoes

• Work on imbalances (hips, core, hamstrings)

• Where are they running?

• Non-weight bearing

• Inserts?

Return to Play Guidelines

• Depends on location and grade of fracture

• Physical therapy needs to address imbalances

• Intensity and duration of training

• Energy imbalances

• Foot orthoses

Return to Sport

• I = 2-4 weeks

• II = 4-6 weeks

• III = 12 weeks

• IV = 16 weeks

• Trabecular takes longer than cortical

Ways to Return

• Anti-G

• Swim jog

• Bike

• Swim

Confounders of Return to Play

• Continued bony pain

• Honesty of patient

Consider obtaining DXA

• >2 stress fractures

• Menarche >16

• History of ED

• BMI <17.5 <85% EW or weight loss of 10% in 1 month

• < 6 menses in 1 year

Consider Beginning Hormones

• Z-score <2.0 and a fracture history (2 stress fractures, high risk fracture or 1 low energy fracture)

• Fail a year of non-pharm therapy to restore menses

• Z-score between -1.0 and -2.0 with fracture and 2 additional Triad risk factors and lack of response to 1 year of non-pharmacological therapy

Future Steps

• Better screening

• Identify more specific risk factors

• Stratify return to play

Questions?

katherine_rizzone@urmc.rochester.edu

Age

Calciotrophic Hormonal Control

Full Disclosure

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Race and Stress Fractures

• Blacks tend to have higher bone densities than whites or Asians

• Black children have higher BMD as compared to white children

• Lower turnover rate?

• Difference in hormones? – both sex and calcitrophic

• More blacks are lactose intolerance