Suzanne Hecht, MD, FACSM, CCD Associate Professor UM Sports Medicine Team Physician; UM Athletics Program Director; UM Sports Med Fellowship
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1 Suzanne Hecht, MD, FACSM, CCD Associate Professor UM Sports Medicine Team Physician; UM Athletics Program Director; UM Sports Med Fellowship
2 Primary Care Sports Medicine Advisory Board for DonJoy Orthopedics NFL Charities Research Grants Chair; Big Ten-Ivy League TBI CIC Research Committe
3 Stress Fx Risk Factors Extrinsic Intrinsic Who needs a DXA? Case
4 Recognize that patients w/ multiple bone stress injuries or a single high risk bone stress injury require further medical evaluation. Learn the risk factors that should prompt a bone health evaluation with a DXA scan.
5 OVERUSE Violate the rule of 2s Poor mechanics Equipment error
6 Genetic Nutrition Endocrine Chronic Diseases Medications Underlying bone tumor/cyst
7 Table 1. Factors prompting BMD evaluation in athletes w/ stress fx Low BMI (< 18.5 kg/m2) Recurrent or multiple stress fxs Oligo/amenorrhea > 6 months H/o an eating disorder, disordered eating or low energy availability Chronic medical conditions associated w/ bone loss Medications associated w/ adverse affects on bone health Cancellous vs. cortical bone fxs, particularly proximal femur, tibial plateau & calcaneus Cyclists, swimmers No recent change in activity level or training intensity Scofield & Hecht: CSMR Nov 2012
8 23 yo female CC: Evaluation of sacral fracture
9 Presented 8/25/10 Severe, sharp R buttock pain 7/19/10 Training run for Houston Marathon intensity Local ER X-rays negative F/u w/ chiropractor Adjustment & MRI ordered
10 Crutches & non-weight bearing student health center DXA scan Lumbar spine Z score = Walking, swimming, elliptical w/out pain Tightness in right buttock 10 lb weight gain since stress fx
11 Tibial stress fx Anorexia Nervosa Amenorrhea Menarche 14, never regular Depression & Anxiety Chronic abdominal pain Lactose, celiac sprue Heart palpitations
12 Meds: Aviane (off last 3 months & no menses yet) Prozac 40mg QD: limited response Ferrous gluconate 325mg QD Calcium 500mg bid & Vit D 1,000 IU/d Omeprazole 20 mg 3-4x/wk Surgical Hx: None Social Hx Sales associate & graduate student Denies tob, alcohol, illegal drug use
13 General Thin, NAD, poor eye contact, withdrawn T 98.6, P 58, RR 12, BP 108/68 Not orthostatic, Wt 108 lbs Ht 64 in BMI 18.5 HEENT, Cor Lungs, Abd, Ext: Normal Skin: Neg No PE stigmata of eating disorder
14 Lumbar spine & hips: FROM, NTTP including sacrum & SI joints Strength 5/5 Mild pelvic obliquity Negative neuro exam Negative single leg hop test Gait: Normal
15 Sacral stress fx Female Athlete Triad Anorexia Nervosa Amenorrhea Osteoporosis Depression & Anxiety H/o tibial stress fx
16 Electrolytes Chemistry panel CBC w/ differential Sed rate Thyroid functions EKG
17 Functional Hypothalamic Amenorrhea FHA is dx of exclusion Pregnancy FSH & LH Estradiol (+/- progesterone challenge) Prolactin TSH Free testosterone & DHEA-S (if indicated) Cortisol (if indicated)
18 Meds glucocorticoids,? SSRI, PPIs, others Genetic Familial hypercalcemic hypocalcuria Hypogonadal states Endocrine Hyperthyroid, hyperparathyroid, cortisol excess Nutritional Deficiency Eating disorder, Vit D, etc Malabsorption Celiac, inflammatory bowel dz
19 Normal labs: CBC, BMP, Phos, Mg, TSH, Iron studies, 25 OH Vit D, prolactin, Urine N-telopeptide, ipth, Alk phos Abnormal labs: Low normal calcium (8.7), ica (4.7) High 24 Urine for calcium 0.45 gm/24 hrs (absorptive hypercalciuria) retest off supplements
20 Non-impact training 3 4 mo Start physical therapy Change training program Eating disorder tx program Psychiatry Consider alternative anti-depressant Retest 24 ůrine for calcium p 2 mo off calcium supplements
21 Returned to running: calcaneus stress fx Unable to train to qualify to Olympic Trials Weight improved Depression improved on Wellbutrin No menses Repeat 24 hr urine calcium: normal Decreasing BMD on f/u DXA
22 Your patients deserve someone thinking about WHY they developed a stress fx/fx. Overtraining is common Poor bone health is uncommon in young Identified early Prevention is best! Don t forget about the males
2014 FEMALE ATHLETE TRIAD COALITION CONSENSUS STATEMENT
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