Stress fracture at the distal tibial metaphysis – note the faint sclerotic line at the tibial metaphysis (Figure 2).

Figure 2. Arrows identifying the stress fracture. Case courtesy of Dr. Hani Makky Al Salam, Radiopaedia.org, rID: 8720

When coupled with the amenorrhea, consider the female athlete triad.

• PEARL: The female athlete triad is a syndrome consisting of disordered eating, amenorrhea, and low bone mineral density (eg. osteoporosis) – Patients will have a degree of dysfunction from all 3 of the components. This is a fairly common disorder in young female athletes but the actual prevalence is hard to estimate because of the complexity of the three components [1]. Studies have shown a range from 0-16% when encompassing all three but can be as high as 4-18% when using two concurrent components and even 16-54% when only looking for one [2,3].
  
  
• PEARL: Stress fractures in competitive athletes is usually multifactorial – increased activity, poor nutrition, and possible hormone imbalance [4,5].

Plain film ankle views should be obtained. If a stress fracture is acute, sensitivity on plain films can be as low as 10% [6]. MRI can be performed outpatient with a sensitivity approaching 100% [4,5,7,8]. A pregnancy test should be performed as well given the amenorrhea. A standard workup for amenorrhea should be performed as an outpatient. Inquire about eating habits and anxiety/depression.

• PEARL: Athletes, regardless of competition level and gender, may be pushed into decreasing caloric intake for the sake of performance, appearance, or making weight. This can have serious physical and mental implications.

The three components of the female triad are on a spectrum of severity in the disruption of bone mineral density/osteoporosis, menstrual dysfunction/dysmenorrhea, and low energy with or without an eating disorder [1,9-11]. Patients will have a degree of dysfunction of all three components.

• PEARL: Risk factors for developing the female athlete triad are participation in sports that emphasize leanness or a specific weight, appearance, or are beneficial if less gravitational forces. These may include gymnastics, ice skating, wrestling, boxing, dance, and track [10,12].

Stress fracture treatment included rest and analgesics. Immobilization is not necessary, but refraining from activity which exacerbates pain is crucial. NSAIDs may be used for pain control [5,7]. Female athlete triad is multifactorial and outpatient follow up should be ensured. Referral to adolescent medicine, sports medicine, or close primary care follow up is important.

• PEARL: The patient will need education on good eating habits and nutrition, decrease in activity, and counseling [1,10,12]. The best way to treat the female athlete triad is to prevent it.