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
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
