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
Disclosures I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services 2
Objectives Review etiology of stress fractures Review diagnostic imaging for pathology Discuss management options Discuss return to play guidelines 3
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 Energy Availability Hormone Balance Bone Health 16
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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 37
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
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 48
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 51
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 65
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