Case of the Young Female Runner

1. Case of the Young Female Runner CDR Steven M. Kriss, FP/Sports Med, FHCC Lovell

2. Disclaimer • This presentation does not represent the opinions of the U.S. Government, the U.S. Navy, the Veteran’s 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 disclose

3. Objectives • To understand 3 aspects of the Female Athlete Triad • To understand that the triad is a spectrum • To understand basic endocrinology of the condition • To understand the sports at risk for the triad • To understand physical exam findings in the triad • To understand the basic treatment for the triad • To understand the multi-disciplinary approach • To understand Title IX and its effects on sports

4. Chief Complaint • R. Foot Pain

5. HPI • 16 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.

6. PMedHx • No HxFxs or Surgeries • Primary Amenorrhea • Diet: Lacto-Vegetarian • Acne • Hyperhidrosis

7. Medications • NKDA • Ibuprofen 600 mg • Benzoyl Peroxide, Topical 5 % Gel • Clindamycin, Topical 1 % lotion

8. Soc Hx • No Tobacco • No Alcohol • Iced Tea

9. FamHx • Not significant

10. Physical Exam • General: • A/O x 3 • Well-Hydrated • Thin for age • NOT well-developed • NOT well-nourished

11. Patients Height/Weight Age: 16 years Height: 60 inches Weight: 95 pounds

12. Weight for Age Chart

13. Stature for Age Chart

14. 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

15. Imaging • AP/LAT/Oblique Foot/Toes : • 1. Step-off Fx of distal second phalanx • 2. Stress Reaction in diaphysis of second MT

16. R. Foot X-Rays

17. Diff Dx • Fractures (2) • Problem Summary List

18. A Triad

19. The Female Athlete Triad

20. The Female Athlete Triad • Historically (defined by ACSM in 1992): Anorexia, Amenorrhea, Osteoporosis • New: Disordered Eating, Menstrual Dysfunction, Low Bone Mineral Density • Why the difference ? We’ll discuss later

21. Background • Title 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 1997 • ACSM developed second position statement in 2007

22. ACSM Position Statement • The 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.

23. Components of the Triad • A spectrum of pathology: • Decreased food intake to eating disorders • Eumenorrhea to Amenorrhea • Osteopenia to Osteoporosis

24. Hypothalamic-Pituitary Axis (HPA)

25. Diagnosis • This is largely a clinical diagnosis • Must exclude other causes of Amenorrhea and Osteopenia • More common in Sports which emphasize leanness: Gymnastics, Figure-Skating, Ballet, Cheerleading, Cross-Country Running

26. Sports at risk for Triad

27. History • Detailed screening history. • Endocrine problems: pituitary, thyroid, PCOS, DM II • Menstrual history: Menarche, length, cycle • Drugs/Meds/OTC/Herbals: Anabolic Steroids • Psycho-Social: Tobacco, Alcohol, Illegal, Abuse, Depression, Anxiety, SI, Significant life stressors • Exercise history: Sport, other work-outs, total hours • Eating Disorder Inventory

28. Physical Exam • Vital Signs: Temp, HR, RR, BP (ranges per ped charts) • Growth Charts (Pediatric and Adult), BMI • General appearance • Basic Pre-Participation Exam: MS, HEENT, Cardiac • Gynecologic, PAP and Breast exam after rapport developed (R/O CA, Congenital issues, STD-s) • Pelvic US if necessary

29. Abnormal findings • Thyroid palpation: R/O Goiter • Parotid glands: R/O hypertrophy from purging • Bulimia: 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 hypercarotenemia

30. Russell’s Sign Callous formation on distal extensor surface of finger used to induce vomiting

31. Fractures • Often 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.

32. Labs • UA and Urine HCG: Volume status; R/O Pregnancy • CBC: R/O Anemia • ESR and CRP: Check for Inflammation and Infection • CMP: electrolytes, liver and kidney function • Thyroid panel: R/O Hypo, Hyperthyroidism (TSH) • FSH and LH: Eval Pituitary and Ovarian function • Prolactin: Eval Pituitary function • Testosterone and DHEA: R/O Androgen excess, tumor • Estradiol: Check levels for ovarian function

33. Imaging • X-Rays: R/O Fx if pain present • DEXA scan: R/O Osteoporosis and baseline bone density • MRI: If clinical/labs suggest Pituitary tumor • Pelvic US: Presence of uterus and ovaries, morphology • Bone Scan: R/O Fx if X-Rays not definitive

34. Treatment • A Multi-Disciplinary treatment team: • Team Physician (FP, ER, IM, Peds) • Nutritionist • Orthopedic Surgeon • Psychiatrist or Psychologist • Cardiologist • Athletic Trainer • Coach • Parents • Friends

35. Treatment • Immobilization of Fractures • Rest or Relative Rest from Sport • Exercise reduction • Increase caloric intake • Supplements (Vit. D, Ca, K, Fe) • Make a contract with athlete to set goals • Temporary removal from team/sport if necessary • Hospitalization (often long-term)

36. Medications • Medications are NO substitute for increasing energy availability ,the cornerstone of restoring normal menstrual , reproductive and bone function • OCPs in those whose BMD declines after NL diet, wt • Progesterone to prevent endometrial hyperplasia • SSRI-s for those with depression, anxiety or OCD

37. Complications • Osteoporosis • Fractures • Infertility • Cardiac Arrhythmias • Possible Cardiovascular effects (adverse lipid profile) • Death

38. Prevention • Early detection with Pre-Participation Exam, quest. • De-emphasize weigh-ins • Education of physicians, coaches, trainers, parents and athletes • Maintain energy availability of 30 kcal/kg /day

39. NewDiscoveries • Leptin, 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 development • Other neuro-hormones like ghrelin may influence menstrual function

40. Young Female Runner Pt • Diagnosis: The Female Athlete Triad • Treatment: • 1. Fracture immobilization in a Walking Boot x 4 wks • 2. No Running or biking; may swim • 3. Rec Nutrition consult and increase caloric intake • 4. Rec Psychiatry consult • 5. X-Rays of Foot before next appt • 6. F/U with Orthopedics Cast Room in 4 wks • 7. D/W Parents and Athlete

41. Summary • The Female Athlete Triad is more prevalent nowadays • A continuum of Disordered Eating, Menstrual Irregularities and Decreased Bone Density • Certain Sports are at higher risk • A Multi-Disciplinary Treatment Team is key • Treatment aimed at increasing caloric intake to roughly 30 kcal/kg/day • Sometimes, Hospitalization is necessary • Complications can be serious, including Death • Prevention through education and screening

42. References • 2007 ACSM Position Stand “The Female Athlete Triad” • 2008 E-Medicine article “Female Athlete Triad” • 2009 Up to Date article “Amenorrhea and Infertility associated with Exercise” • The Little Black Book of Sports Medicine • Clinical Sports Medicine by Brukner

43. Thank You