Epidemiology, Diagnosis and Management of the Female Athlete Triad

Transcription

1 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

2 Disclosures I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services 2

3 Objectives Review etiology of stress fractures Review diagnostic imaging for pathology Discuss management options Discuss return to play guidelines 3

4 Peak Bone Mass 90% of peak bone mass is formed by age 18

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6 What Controls Bone Health? Bone remodeling is constant Balance between breaking down and building back up Hormones Age Diet Medications Activity

7 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

8 What is a Stress Fracture? Microfracture of a bone from repetitive stress

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10 Epidemiology of Stress Fractures Females >> Males Common locations: Metatarsals Tibia Fibula Sport dependent Track vs baseball vs rowing

11 Known Risks for Stress Fractures Hormonal imbalance Poor dietary intake of bone building/stabilizing nutrients Previous stress fractures Gender Race

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13 Female Athlete Triad

14 Dr. Rizzone s Triad Energy Availability Hormone Balance Bone Health 16

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16 EA and Hormones If you don t eat enough Decr GnRH Decr estrogen and testosterone Trying to save energy Decr Thyroid hormones

17 Hormones and Stress Fractures Sex hormones control bone remodeling through osteoclasts and osteoblasts osteoclast activity

18 Hormones and Stress Fractures estrogen and testosterone bone turnover

19 Take a good menstrual history Menarche Amenorrhea/Oligomenorrhea On birth control? OCP s, shot, IUD

20 Diagnosis Clinical Imaging

21 Diagnosis Clinical: History Exam Imaging: X-ray MRI Bone scan Ultrasound

22 Diagnosis Clinical History: mileage, changes in exercise level Exam: pain over specific spot

23 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: % sens but less spec than MRI Ultrasound:? Future?

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31 Reaction vs. Fracture Stress reaction Periosteal or marrow edema without fracture line Stress fracture Periosteal or marrow edema with fracture line

32 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

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34 T1 versus T2 37

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

36 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

37 Medium Risk Stress Fractures Pelvis Femoral shaft Proximal tibia Cuboid Cuneiform

38 Medium Risk Stress Fracture Immobilize Can do pain-free activity

39 Low Risk Stress Fracture Posteromedial tibia Fibula Calcaneus Distal metatarsals 2-5

40 Low Risk Stress Fractures Immobilize if pain with ambulation Pain-free activity

41 Laboratory Work-up

42 What? CBC CMP Vit D PTH TSH Mg Urine labs

43 Who? Recurrent stress injuries Trabecular fractures: femoral neck, sacrum, pelvis Fractures with low trauma

44 Recovery

45 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 48

46 Calcium and Vitamin D

47 Treatment for low EA **Fix the imbalance** Increase intake Decrease energy needs

48 Treatment for abnormal menses *Pregnancy test Treat low EA Rare: work-up for metabolic disease Rare: work-up for other hormonal issues 51

49 Treatment for bone abnormalities Treat low EA Supplementation NSAIDS:? Biphosphanates? OCP s? Bone stimulation

50 Other factors Review gait Shoes Work on imbalances (hips, core, hamstrings) Where are they running? Non-weight bearing Inserts?

51 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

52 Return to Sport I = 2-4 weeks II = 4-6 weeks III = 12 weeks IV = 16 weeks Trabecular takes longer than cortical

53 Ways to Return Anti-G Swim jog Bike Swim

54 Confounders of Return to Play Continued bony pain Honesty of patient

55 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

56 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

57 Future Steps Better screening Identify more specific risk factors Stratify return to play

58 Questions?

59 Age

60 Calciotrophic Hormonal Control

61 Full Disclosure 65

62 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