Case of the Young Female Runner

Case of the Young Female RunnerCDR Steven M. Kriss, FP/Sports Med, FHCC Lovell1

DisclaimerThis presentation does not represent the opinions of the U.S. Government, the U.S. Navy, the Veterans Administration or the Federal Health Care Center James A. Lovell (FHCC Lovell)

There are no financial relationships or unapproved or off-label product uses to disclose2 ObjectivesTo understand 3 aspects of the Female Athlete TriadTo understand that the triad is a spectrumTo understand basic endocrinology of the conditionTo understand the sports at risk for the triadTo understand physical exam findings in the triadTo understand the basic treatment for the triadTo understand the multi-disciplinary approachTo understand Title IX and its effects on sports

3 Chief ComplaintR. Foot Pain4 HPI16 yo USN dep female Runner (runs 50 miles/wk) presents with R. Foot Pain since 21 NOV 2009.Pain started while running in a X-Country race on a hill.The next week she ran a second race; had more pain.

5 PMed Hx No Hx Fxs or SurgeriesPrimary AmenorrheaDiet: Lacto-VegetarianAcneHyperhidrosis

6 MedicationsNKDAIbuprofen 600 mgBenzoyl Peroxide, Topical 5 % GelClindamycin, Topical 1 % lotion7 Soc HxNo TobaccoNo AlcoholIced Tea8 Fam HxNot significant 9 Physical ExamGeneral: A/O x 3Well-HydratedThin for ageNOT well-developedNOT well-nourished

10 Patients Height/Weight Age: 16 yearsHeight: 60 inchesWeight: 95 pounds11 Weight for Age Chart12

Stature for Age Chart13

Musculoskeletal Exam Slightly antalgic Gait, favoring L. Foot R. Foot:+Ecchymosis+TTP over dorsal aspect R. Second MT Pain with ROM of R. Second MT

14 Imaging AP/LAT/Oblique Foot/Toes :1. Step-off Fx of distal second phalanx2. Stress Reaction in diaphysis of second MT15 R. Foot X-Rays16

Diff DxFractures (2)Problem Summary List17 A Triad18

The Female Athlete Triad19

The Female Athlete TriadHistorically (defined by ACSM in 1992): Anorexia, Amenorrhea, Osteoporosis

New: Disordered Eating, Menstrual Dysfunction, Low Bone Mineral Density

Why the difference ? Well discuss later20 BackgroundTitle IX was signed into law in 1972, increasing funding for female sports at all levels and increasing female participation in sports. This increased the incidence of a particular syndrome more common in female athletes than in the female non-athlete population.

ACSM developed first position statement in 1997ACSM developed second position statement in 200721 ACSM Position StatementThe Female Athlete Triad refers to the relationships between energy availability, menstrual function and bone mineral density.The clinical manifestations include eating disorders, functional hypothalamic amenorrhea and osteoporosis.Energy availability is defined as dietary energy intake minus exercise energy expenditure.Low energy availability is the factor that impairs reproductive and skeletal health in the Triad.22 Components of the TriadA spectrum of pathology:Decreased food intake to eating disordersEumenorrhea to AmenorrheaOsteopenia to Osteoporosis

23 Hypothalamic-Pituitary Axis (HPA)24

DiagnosisThis is largely a clinical diagnosisMust exclude other causes of Amenorrhea and OsteopeniaMore common in Sports which emphasize leanness: Gymnastics, Figure-Skating, Ballet, Cheerleading, Cross-Country Running25 Sports at risk for Triad26

HistoryDetailed screening history.Endocrine problems: pituitary, thyroid, PCOS, DM IIMenstrual history: Menarche, length, cycleDrugs/Meds/OTC/Herbals: Anabolic SteroidsPsycho-Social: Tobacco, Alcohol, Illegal, Abuse, Depression, Anxiety, SI, Significant life stressorsExercise history: Sport, other work-outs, total hours Eating Disorder Inventory

27 Physical ExamVital Signs: Temp, HR, RR, BP (ranges per ped charts)Growth Charts (Pediatric and Adult), BMIGeneral appearanceBasic Pre-Participation Exam: MS, HEENT, CardiacGynecologic, PAP and Breast exam after rapport developed (R/O CA, Congenital issues, STD-s)Pelvic US if necessary28 Abnormal findingsThyroid palpation: R/O GoiterParotid glands: R/O hypertrophy from purgingBulimia: bloodshot eyes and petechiae of sclera/cheeks.Dental exam: dental caries from stomach acid.Anorexia may cause bradycardia and hypotension.ECG for above and for baseline.Dermatologic exam: lanugo and hypercarotenemia29 Russells Sign30

Callous formation on distal extensor surface of finger used to induce vomiting FracturesOften the first manifestation of the Triad.May have a history of past fractures.Bone Mineral Density (BMD) can be affected.A result of amenorrhea, decreased estrogen and poor nutrition.

31 LabsUA and Urine HCG: Volume status; R/O Pregnancy CBC: R/O AnemiaESR and CRP: Check for Inflammation and InfectionCMP: electrolytes, liver and kidney functionThyroid panel: R/O Hypo, Hyperthyroidism (TSH)FSH and LH: Eval Pituitary and Ovarian functionProlactin: Eval Pituitary functionTestosterone and DHEA: R/O Androgen excess, tumorEstradiol: Check levels for ovarian function

32 ImagingX-Rays: R/O Fx if pain presentDEXA scan: R/O Osteoporosis and baseline bone densityMRI: If clinical/labs suggest Pituitary tumorPelvic US: Presence of uterus and ovaries, morphologyBone Scan: R/O Fx if X-Rays not definitive33 TreatmentA Multi-Disciplinary treatment team:Team Physician (FP, ER, IM, Peds)NutritionistOrthopedic Surgeon Psychiatrist or PsychologistCardiologistAthletic TrainerCoachParentsFriends34 TreatmentImmobilization of FracturesRest or Relative Rest from SportExercise reductionIncrease caloric intakeSupplements (Vit. D, Ca, K, Fe)Make a contract with athlete to set goalsTemporary removal from team/sport if necessaryHospitalization (often long-term)

35 MedicationsMedications are NO substitute for increasing energy availability ,the cornerstone of restoring normal menstrual , reproductive and bone functionOCPs in those whose BMD declines after NL diet, wtProgesterone to prevent endometrial hyperplasiaSSRI-s for those with depression, anxiety or OCD

36 Complications OsteoporosisFracturesInfertilityCardiac ArrhythmiasPossible Cardiovascular effects (adverse lipid profile)Death

37 PreventionEarly detection with Pre-Participation Exam, quest.De-emphasize weigh-insEducation of physicians, coaches, trainers, parents and athletesMaintain energy availability of 30 kcal/kg /day 38 New DiscoveriesLeptin, a hormone secreted by fat cells in proportion to body fat stores may have effects on reproductive function.Rodents deficient in leptin do not have NL pubertal developmentOther neuro-hormones like ghrelin may influence menstrual function39 Young Female Runner PtDiagnosis: The Female Athlete TriadTreatment: 1. Fracture immobilization in a Walking Boot x 4 wks2. No Running or biking; may swim3. Rec Nutrition consult and increase caloric intake4. Rec Psychiatry consult5. X-Rays of Foot before next appt6. F/U with Orthopedics Cast Room in 4 wks7. D/W Parents and Athlete40 SummaryThe Female Athlete Triad is more prevalent nowadays A continuum of Disordered Eating, Menstrual Irregularities and Decreased Bone DensityCertain Sports are at higher riskA Multi-Disciplinary Treatment Team is keyTreatment aimed at increasing caloric intake to roughly 30 kcal/kg/daySometimes, Hospitalization is necessaryComplications can be serious, including DeathPrevention through education and screening

41 References2007 ACSM Position Stand The Female Athlete Triad2008 E-Medicine article Female Athlete Triad2009 Up to Date article Amenorrhea and Infertility associated with ExerciseThe Little Black Book of Sports MedicineClinical Sports Medicine by Brukner

42 Thank You 43