Stress fracture of capitate bone-A case report of an unusual fracture.

INTRODUCTION: The capitate is the largest, most central bone and the first to ossify in the wrist. It has a well-protected anatomic location, making traumatic or stress fractures extremely rare in clinical practice. Isolated fractures of the capitate bone are very uncommon and often without displacement due to the great stability provided by the intracarpal ligaments. PURPOSE OF THE STUDY: This study aimed to report a case of isolated stress fracture of the capitate related to the work activity of a mechanic. CASE REPORT: We report the case of a 23-year-old patient complaining of pain and swelling in the left wrist for 2 months without improvement after using analgesics. On physical examination, he presented pain on palpation in the central region of the wrist, pain when performing flexion and extension movements of the wrist, and frustrated edema. Magnetic resonance imaging diagnosed a stress fracture of the capitate bone. Conservative treatment with forearm-palmar immobilization for 2 months, analgesic medication, and physical therapy rehabilitation after immobilization were performed. After the complete resolution of the symptoms, the patient started to work in a new role. DISCUSSION: There are five case reports of stress fractures in the capitate-two in teenagers and three in adults, but none of them was a mechanic. Clinical suspicion can be formulated when repetitive activity is associated with the wrist in extension and specific location of pain and swelling. Individuals with an immature skeleton are more susceptible. The development of occupational disease should be considered in similar cases of insidious and persistent pain in the palm of people with high work demands. CONCLUSION: Stress fractures of the capitate bone are a disease that must be suspected in insidious and persistent pain in the palm of the hand. Magnetic resonance imaging is the best image test to diagnose this disorder, and conservative treatment is indicated.

Low energy availability reduces bone mass and gonadal function in male mice.

INTRODUCTION: In women, the female athlete triad, marked by low energy availability, functional hypothalamic amenorrhea and osteoporosis, is a recognized risk for stress fractures. Stress injuries also occur in men, but by contrast risks and mechanisms underlying them are less characterized. MATERIALS AND METHODS: 5 week-old wild-type male mice were fed ad libitum (ad) or subjected to 60% food restriction (FR) for five weeks. In both groups, some mice were allowed access to an exercise wheel in cages to allow voluntary wheel running (ex) and/or treated with active vitamin D analogues. Mice were sacrificed and analyzed at 10 weeks of age. RESULT: Male FR mice exhibited significantly reduced testicle weight, serum testosterone levels and bone mass. Such bone losses in FR male mice were enhanced by exercise. Histological analysis revealed that both bone-resorbing and -forming activities were significantly reduced in FR or FR plus exercise (FR + ex) mice, mimicking a state of low bone turnover. Significantly reduced bone mass in FR or FR + ex male mice was significantly rescued by treatment with active vitamin D analogues, with significant restoration of osteoblastic activities. Serum levels of insulin-like growth factor I (IGF-I), which is critical for bone remodeling, were significantly lower in FR versus control male mice. CONCLUSIONS: Low energy availability puts men at risk for stress injuries as well, and low energy availability is upstream of gonadal dysfunction and osteoporosis in males. Active vitamin D analogues could serve as therapeutic or preventive options for stress injuries in men.

Impact of accumulating risk factors on the acromial and scapular fracture rate after reverse total shoulder arthroplasty with a medialized glenoid-lateralized humerus onlay prosthesis.

BACKGROUND: Identifying risk factors for acromial and scapular fractures improves our understanding about which variables are relevant to these fracture complications; however, these data are difficult to integrate into clinical practice because the majority of reverse total shoulder arthroplasty (rTSA) patients have ≥1 risk factor. The goal of this study was to better facilitate preoperative identification of patients at risk of acromial and scapular fractures and quantify the impact of accumulating risk factors on the incidence of fracture. METHODS: We retrospectively analyzed 9079 rTSA patients from a multicenter database of rTSA procedures performed with a single medialized glenoid-lateralized humerus onlay rTSA prosthesis to quantify the rate of acromial and scapular fractures. Univariate and multivariate analyses were performed to identify risk factors for fracture. Next, we quantified the number of patients with 1 or multiple significant risk factors for fracture. Finally, to facilitate preoperative identification of patients most at risk of fracture, we stratified our data set using multiple combinations of age, sex, and diagnosis risk factors and calculated the odds ratio for each cohort to quantify the impact of accumulating risk factors on the incidence of fracture. RESULTS: A fracture of the acromion or scapula was radiographically identified in 138 of 9079 patients, for a rate of 1.52%. Patients with fractures were more likely to be older, of female sex, to have a diagnosis of rheumatoid arthritis and/or cuff tear arthropathy, and were less likely to have a diagnosis of diabetes. Eighty-five percent of rTSA patients had ≥1 fracture risk factor. Individually, age, sex, or diagnosis failed to identify any patient cohort with an odds ratio >2.5. Use of multiple combinations of patient risk factors refined the identification of at-risk patients better than any individual risk factor or 2-risk factor combination and demonstrated that the patients with the greatest fracture risk were female patients with a rheumatoid arthritis diagnosis who were aged >70, >75, and >80 years. CONCLUSION: This 9079-rTSA multicenter study demonstrated that 1.52% of patients experienced acromial and/or scapular fractures with a single medialized glenoid-lateralized humerus onlay rTSA prosthesis. Our analysis identified numerous risk factors and quantified the impact of accumulating risk factors on fracture incidence. Patients who are considering rTSA and who have these age, sex, and diagnosis risk factors should be made aware of their elevated complication risk.

[Nutritional factors of bone health in athletes].

The importance of proper nutrition when playing sports is difficult to overestimate. Athletes of any age need to consume a sufficient amount of macro- and micronutrients for bone health. High-quality and balanced nutrition in terms of quantity and composition is important for optimal recovery after training, adaptation to intense physical activity and prevention of sports injuries. The aim of the study was to summarize the current data of domestic and foreign literature on the factors affecting bone mineral density (BMD) in athletes, as well as to consider the key points of nutritional support necessary for the prevention and treatment of osteoporosis. Material and methods. The search was conducted using the Google Academy search engine and electronic databases PubMed, MEDLINE, EMBASE, Scopus, Web of Science, eLIBRARY for the period from 2008 to 2022. For the search, we used keywords and their combinations: "athletes", "osteoporosis", "stress fractures", "calcium" and "vitamin D". Results and discussion. Bone health is influenced by many factors, the most significant of which are lifestyle and the nature of a person's physical activity. Despite strong evidence for the benefits of exercise for bone health, there are sports that predispose to low BMD and increase the risk of osteoporosis. First of all, athletes involved in aerobic and aesthetic disciplines (long-distance running, cycling, swimming, rhythmic gymnastics, dancing, etc.) are at risk. In addition, factors that predispose to a decrease in BMD include female gender, low intake of energy substrates, protein, vitamin D and calcium, and certain medications. Of great importance for the regulation of bone metabolism and maintaining optimal BMD are the genetic characteristics of the athlete. The main adverse consequences for athletes with reduced BMD are fractures of various localization. At the same time, the problem of a high risk of developing stress injuries of bones is especially relevant. Calcium and vitamin D are key nutritional factors needed to maintain bone health. Optimal intake of carbohydrates, proteins, and polyunsaturated fatty acids is also important. There is evidence of a positive effect on the skeletal system of such nutritional factors as potassium, magnesium, sodium, vitamins K, C, B12 and folic acid. The specific mechanisms of the influence of these micronutrients on bone metabolism and the relationship of their consumption level with BMD need further research. Conclusion. Thus, athletes of all ages and specializations need to pay great attention to the state of the skeletal system. Given the association between the risk of osteoporosis and malnutrition, it is essential for athletes to maintain an optimal nutritional status and consume adequate amounts of vitamins and minerals.

Bilateral Atypical Femur Fractures After Denosumab in a Bisphosphonate Naive Patient: A Case Report.

A case report of bilateral atypical femur fractures (AFF) in a bisphosphonate naive patient. A 62-year-old female bisphosphonate naive patient was started on denosumab for osteoporosis. Approximately 3 years later she complained of right hip pain and was found to have a bilateral incomplete AFFs. She was asymptomatic on the left lower limb. Patient was managed conservatively and placed on protected weight bearing on both legs. Symptoms subsequently resolved over a period of 3 months, although radiographic findings remained at approximately 1 year. AFFs may be associated with patients on denosumab therapy even without a prior history of bisphosphonate use. Patients should be counselled appropriately and monitored for such complications.

Comparison of Ultrasonography to MRI in the Diagnosis of Lower Extremity Bone Stress Injuries: A Prospective Cohort Study.

OBJECTIVE: To determine the sensitivity and specificity of ultrasound imaging (USI) compared to the reference-standard of MRI in the diagnosis of bone stress injury (BSI). METHODS: A prospective blinded cohort study was conducted. Thirty seven patients who presented to an academic sports medicine clinic from 2016 to 2020 with suspected lower-extremity BSI on clinical exam underwent both magnetic resonance imaging (MRI) and USI. Participant characteristics were collected including age, gender and sport. Exclusion criteria included contraindication for dedicated MRI, traumatic fracture, or severe tendon or ligamentous injury. The primary outcome measure was BSI diagnosis by USI. An 8-point assessment system was utilized on USI for diagnosis of BSI, and the Fredericson and Nattiv22 criteria were applied to classify MRI findings. RESULTS: Thirty seven participants who met study criteria were consented to participate. All participants completed baseline measures. Using MRI, there were 30 (81%) athletes with a positive and seven participants with a negative BSI diagnosis. The most common BSIs in the study were in the metatarsal (54%) and tibia (32%). Compared to MRI, USI demonstrated 0.80 sensitivity (95% confidence interval [CI], 0.61-0.92) and 0.71 specificity (95% CI, 0.29-0.96) in detecting BSI, with a positive predictive value of 0.92 (95% CI, 0.75-0.99) and negative predictive value of 0.45 (95% CI, 0.17-0.77). CONCLUSIONS: USI is a potentially useful point-of-care tool for practicing sports medicine providers to combine with their clinical evaluation in the diagnosis of BSIs. Further research is ongoing to determine the role of USI in follow-up care and return-to-play protocols.

[Musculoskeletal laboratory diagnostics in competitive sport]. / Muskuloskelettale Labordiagnostik im Leistungssport.

BACKGROUND: Laboratory diagnostics represent a valuable tool for the optimization and assessment of the performance and regeneration ability in professional athletes. Blood parameters play an important role in the prevention, diagnosis and rehabilitation of injuries and physical overload. OBJECTIVES: The aim of this article is to present an overview of musculoskeletal laboratory parameters and to provide relevant information for the medical care of competitive athletes. METHODS: Literature search and narrative review. RESULTS: The laboratory assessment of bone metabolism includes vitamin D, calcium and bone turnover and aims to provide a preventive benefit with respect to skeletal complications (e.g., to minimize the risk of bone stress injuries). In addition, muscular serum markers, such as lactate dehydrogenase (LDH), creatine kinase (CK), myoglobin and aspartate aminotransferase (AST) can be used to monitor metabolic adaptation to physical exercise and to obtain information about the muscular workload and potential damage. The energy availability can be estimated and optimized by appropriate balancing and laboratory determination of macro- and micronutrients. CONCLUSIONS: Laboratory diagnostics have a clinical relevance across different sport disciplines. They are intended to support athletes and medical staff on their way to the highest possible performance and help to ensure the optimal prevention of bone and muscle injuries. Parameters with deficiency results (e.g., vitamin D) should be adequately compensated. A periodization of the laboratory tests, with at least two tests per year, and the establishment of individual variability and reference ranges can improve the assessment.

Multiple ipsilateral femoral stress fractures in a patient taking denosumab for osteoporosis-a case report.

This is the first report describing three ipsilateral femoral stress fractures in a patient taking denosumab. INTRODUCTION: Multiple reports of atypical femur fractures (AFF) in patients receiving denosumab have emerged recently. Denosumab is an anti-resorptive agent approved for treatment of osteoporosis. It is a human monoclonal antibody which blocks osteoclast activation, maturation, and function. METHODS: This is a case report of a 74-year-old female patient who sustained three stress fractures of her left femur. RESULTS: The patient healed her fractures after intramedullary nailing of the femur and was able to return to her activities. CONCLUSIONS: High index of suspicion is needed in any patient with osteoporosis on denosumab complaining of thigh or groin pain. Careful examination and radiographic studies of both femurs are warranted if AFF is discovered.

Risk factors of stress fractures due to the female athlete triad: Differences in teens and twenties.

BACKGROUND: The female athlete triad (Triad), defined by the American College of Sports Medicine as low energy availability (LEA) with or without disordered eating, menstrual dysfunction, and low bone mineral density (BMD), is associated with stress fractures and athletes aged 16-17 years are most susceptible. PURPOSE: To examine whether the Triad increases the risk of stress fractures, athletes were assigned to a "teenage" group and a "20s" group. METHODS: This prospective study enrolled 390 elite female athletes and was conducted from 2012 to 2016 at Japan Institute of Sports Sciences. Blood concentrations of various hormones were examined, and BMD was measured at the lumbar spine and throughout the whole body using dual-energy X-ray absorptiometry. LEA was defined as body weight ≤85% of the ideal body weight for teenage athletes, or BMI ≤17.5 for athletes in their 20s. Low BMD was defined as a BMD Z-score of <-1.0 in the lumbar spine and the whole body. RESULTS: Among 390 athletes enrolled, 36 developed new stress fractures within 3 months of registration. The risk for stress fractures due to the Triad in teenage athletes was higher than for athletes in their 20s. In teenage female athletes, secondary amenorrhea, low BMD for the whole body, and a low ratio of actual body weight to ideal body weight increased the risk for stress fractures by 12.9 times, 4.5 times, and 1.1 times, respectively. CONCLUSION: To prevent stress fractures in female athletes with the Triad, age of athletes should be taken into consideration.

Regular physical exercise before entering military service may protect young adult men from fatigue fractures.

BACKGROUND: Bone stress fractures are overuse injuries commonly encountered in sports and military medicine. Some fatigue fractures lead to morbidity and loss of active, physically-demanding training days. We evaluated the incidence, anatomical location, risk factors, and preventive measures for fatigue fractures in young Finnish male conscripts. METHODS: Five cohorts of 1000 men performing military service, classified according to birth year (1969, 1974, 1979, 1984, 1989), were analysed. Each conscript was followed for his full military service period (180 days for conscripts with rank and file duties, 270 days for those with special training, 362 days for officers and highly trained conscripts). Data, including physical activity level, were collected from a standard pre-information questionnaire and from the garrisons' healthcare centre medical reports. Risk factor analysis included the conscripts' service class (A, B), length of military service, age, height, weight, body mass index, smoking, education, previous diseases, injuries, and subjective symptoms, as well as self-reports of physical activity before entering the service using a standard military questionnaire. RESULTS: Fatigue fractures occurred in 44 (1.1%) of 4029 men, with an incidence of 1.27 (95% confidence interval: 0.92-1.70) per 1000 follow-up months, and mostly (33/44, 75%) occurred at the tibial shaft or metatarsals. Three patients experienced two simultaneous stress fractures in different bones. Most fatigue fractures occurred in the first 3 months of military service. Conscripts with fatigue fractures lost a total of 1359 (range 10-77) active military training days due to exemptions from duty. Conscripts reporting regular (> 2 times/week) physical activity before entering the military had significantly fewer (p = 0.017) fatigue fractures. Regular physical activity before entering the service was the only strong explanatory, protective factor in the model [IRR = 0.41 (95% CI: 0.20 to 0.85)]. The other measured parameters did not contribute significantly to the incidence of stress fractures. CONCLUSION: Regular and recurrent high-intensity physical activity before entering military service seems to be an important preventive measure against developing fatigue fractures. Fatigue fractures should be considered in conscripts seeking medical advice for complaints of musculoskeletal pain, and taken into consideration in planning military and other physical training programs.

Medial iliac stress fractures in athletes: report of two rare cases: review of literature and clinical recommendations.

Stress fractures are a common diagnosis in sports medicine and can result in significant loss of function, athlete playing time, and potentially lead to chronic symptoms. However, unusual locations of stress fractures may present with vague symptoms and a relatively benign physical exam, leading to difficulty in arriving at the correct diagnosis. Pelvic stress fractures are less common than lower-extremity stress fractures in athletes, occurring in only 1-5% of all stress fractures and typically occur in pubic rami. Furthermore, iliac bone stress fractures are even rarer, with only a few case reports in the literature. Their presentation can easily be missed on routine workup and imaging. We present two cases of the very rare superomedial iliac bone stress fracture in athletes, an unusual location for this uncommon stress fracture. We review the available literature on this condition and provide clinical commentary on workup and treatment recommendations.

[Differential diagnoses of osteonecrosis of large joints]. / Differenzialdiagnosen der Osteonekrose großer Gelenke.

Subchondral insufficiency fractures and idiopathic bone marrow edema syndrome are the most important differential diagnoses to be distinguished from osteonecrosis because they have a deviating and as a rule more favorable prognosis and also different therapeutic strategies. Osteochondritis dissecans represents a different entity in many respects, which should not be confused or unified with osteonecrosis. Based on recent knowledge intractable subchondral insufficiency fractures may be the underlying cause of rapidly destructive osteoarthritis at least in some cases. Septic involvement of bone and joints can eo ipso cause severe articular damage due to direct destruction but also secondary to septic vascular occlusion resulting in septic osteonecrosis. Whereas bone marrow infiltrating systemic diseases and the therapeutic regimens can lead to osteonecrosis, bone tumors or tumor-like diseases, rarely pose a differential diagnostic problem with respect to the differentiation from osteonecrosis.

A complete posterior tibial stress fracture that occurred during a middle-distance running race: a case report.

Posterior tibial stress fractures are more frequent than anterior tibial stress fractures, and they are considered to have a good prognosis for returning to sports; cases leading to a complete fracture are rare. A 17-year-old male involved in high school athletics middle-distance running had a 3-week history of pain with training. He was running up to 300 km/week on streets and cross-country in an even distribution. He had posterior tibial stress fractures, but despite the lower leg pain, he continued running. One year later, he was brought to the emergency department after having sustained an injury to the right lower leg while running in a middle-distance race; bilateral tibial stress fractures, with one side complete and the opposite side incomplete, had developed simultaneously. This relatively rare case of bilateral posterior stress fractures, with one side a complete fracture and the opposite side an incomplete fracture, that was treated surgically via exchange intramedullary nailing is reported. The patient could begin light jogging from 3 months after surgery and was without symptoms at 5 months after surgery. He could resume middle-distance racing after 1 year. Posterior tibial cortical fractures are more common and respond better to conservative treatment than anterior tibial stress fractures, and they are a common fracture type in runners. We believe that close, careful follow-up is necessary if patients continue excessive training.

[Sport climbing, bouldering and associated injuries in childhood and adolescence]. / Sportklettern, Bouldern und assoziierte Verletzungen im Kindes- und Jugendalter.

BACKGROUND: Sport climbing and bouldering has developed from a rarely performed to a very popular sport in the last 30 years. Sport physicians are increasingly faced with its specific and otherwise uncommon injury pattern. Overall, the sport is relatively safe, particularly if performed in indoor facilities. INJURIES: The injuries frequently occur on the upper extremity, with the fingers being the most affected. Acute traumatic lesions such as sprains, fractures or ligament lesions are much rarer than overload and overuse caused by repetitive and highly stressing climbing movements. The most common injury is not the pulley rupture, as in adults, but the epiphyseal stress fracture of the base of the middle phalanx, which occurs practically only in climbing sport. The injury is treated conservatively, has a long recovery time of about 8 months and may lead to joint destruction and arthrosis if missed.

[Differential diagnoses of osteonecrosis of large joints]. / Differenzialdiagnosen der Osteonekrose großer Gelenke.

Subchondral insufficiency fractures and idiopathic bone marrow edema syndrome are the most important differential diagnoses to be distinguished from osteonecrosis because they have a deviating and as a rule more favorable prognosis and also different therapeutic strategies. Osteochondritis dissecans represents a different entity in many respects, which should not be confused or unified with osteonecrosis. Based on recent knowledge intractable subchondral insufficiency fractures may be the underlying cause of rapidly destructive osteoarthritis at least in some cases. Septic involvement of bone and joints can eo ipso cause severe articular damage due to direct destruction but also secondary to septic vascular occlusion resulting in septic osteonecrosis. Whereas bone marrow infiltrating systemic diseases and the therapeutic regimens can lead to osteonecrosis, bone tumors or tumor-like diseases, rarely pose a differential diagnostic problem with respect to the differentiation from osteonecrosis.

[Finger and shoulder injuries in rock climbing]. / Finger- und Schulterverletzungen im Klettersport.

BACKGROUND: Sport climbing is rapidly becoming a popular trend sport, which has resulted in a surge of climbing-specific injuries. OBJECTIVES: The goal of this paper is to delineate the incidence of climbing-specific injuries focusing on finger and shoulder injuries. Furthermore, we aim to illustrate clinical symptoms and therapeutic strategies based on the current literature. MATERIALS AND METHODS: The incidence of climbing-specific injuries in a large patient population was recorded and diagnosis and treatment options were assessed considering the current literature. RESULTS: Finger and shoulder injuries are the most common entities in sport climbing. With regard to finger injuries, more than 30 different differential diagnoses were identified, with pulley injuries, tenosynovitis, epiphyseal fractures, as well as lumbrical muscle tears being of the greatest importance due to their climbing-specific nature. With regard to shoulder injuries, SLAP lesions play a particularly important role, currently representing the fifth most common diagnosis in the patient population analyzed. Further pathologies that are becoming increasingly important among sport climbers are injuries of the rotator cuff, long biceps tendon ruptures, impingement syndromes and injuries caused by shoulder dislocations (e.g. Bankart lesions). CONCLUSIONS: Finger injuries are common in sports climbing and can be challenging to diagnose and treat correctly. The number of shoulder injuries is expected to rise as new competition modalities and sub-disciplines (e.g. bouldering) increasingly stress athletes' musculoskeletal systems. An increase of degenerative injuries in long-time climbers is expected due to changes in the sport.

Stress fractures in military recruits: A prospective study for evaluation of incidence, patterns of injury and invalidments out of service.

BACKGROUND: Stress fractures (SFs) occur because of repetitive submaximal stresses to the bone over a period of time. SFs cause an economic loss to the organization and to the individuals who get invalided out of army because of SFs. This study was conducted to determine the incidence, distribution, onset of SFs, and invalidment patterns due to SFs. METHODS: This prospective study was carried out among recruits undergoing training at training centres in a cantonment of Central India. The recruits enrolled were followed up through their training period for occurrence of SF. On occurrence of SF, the clinical features, site of bone involved, and the weeks of completed military training were noted. The SFs were graded into four grades based on clinicoradiological features and managed accordingly. RESULTS: A total of 8974 recruits were enrolled into the study, of which 208 recruits suffered SFs. The commonest bone involved was the tibia (86.5%), commonest site being the proximal one-third of the tibia shaft (46.2%). Average week of developing SF was the 15th week of training. Seven recruits were invalided out of army because of SFs, the commonest cause being femoral neck SFs. CONCLUSION: Prevention is the best approach for SFs. It is suggested to increase the intensity of training gradually over the first 16 weeks and recruits are to be given a training pause at around the 12th week for healing of stressed bones just before the peak time of occurrence of SFs. Femoral neck SFs are the commonest SFs responsible for invalidment of recruits.

Stress Fractures of the Calcaneus Diagnosed by Sonography: Report of 8 Cases.

We present a retrospective review of 8 patients (6 women and 2 men, with an age range of 46-80 years; mean age, 60.2 years) in whom sonography was used to diagnose a calcaneal stress fracture. Sonography was performed because of a clinical suspicion of soft tissue injuries. Two patients were first assessed by standard radiography; for the remaining patients, sonography was the first imaging technique used. Patients were subsequently examined by magnetic resonance imaging, except for 1 patient in whom the diagnosis was made only on a clinical-sonographic correlation. On sonography, there was thickening of the periosteum and subcutaneous edema in all patients; a calcified bone callus was evident in none of the 8 patients. Cortical irregularities were found in 6 of 8 patients. Color Doppler imaging showed local hypervascular changes of the periosteum in all patients. Sonography, together with clinical findings, can be used to diagnose a calcaneal stress fracture. We suggest that sonologists should include a calcaneal stress fracture in their differential diagnosis in cases of mechanical hind foot pain. They must also include, as a part of every sonographic examination of the ankle, an examination of the calcaneus and be aware of the sonographic appearance of stress fractures. If the diagnosis is still uncertain after the sonographic examination, magnetic resonance imaging should be prescribed.

A Review and Proposed Rationale for the use of Ultrasonography as a Diagnostic Modality in the Identification of Bone Stress Injuries.

Bone stress injuries are common in military personnel and athletes. The delayed diagnosis of a bone stress injury can lead to a more severe injury that requires a longer period of treatment. The early detection of bone stress injuries is a central part of management. Currently, the reference standard for detecting bone stress injuries is magnetic resonance imaging. However, the expanding use of point-of-care ultrasonography (US) may enable the early detection of bone stress injuries in the clinical setting. In this article, we review the US detection of bone stress injuries, as well as discuss the rationale for the use of US in the diagnosis of these injuries.

Management of the female athlete triad.

The female athlete triad (FAT) is defined by the American College of Sports Medicine (ACSM) as low energy availability (low EA), functional hypothalamic amenorrhoea and osteoporosis. In low EA, lutein dysfunction first develops, followed by anovulation and, subsequently, oligomenorrhea, leading to amenorrhea. Moreover, low estradiol concentrations due to amenorrhea decrease bone mineral density (BMD). In athletes with one of the factors of FAT, the risk of a stress fracture is 2.4-4.9 times higher and may increase the risk of fracture throughout the lifespan. Low EA is the starting point of FAT, and the FAT concept emphasizes the importance of energy intake that is commensurate with exercise energy expenditure in athletes. In amenorrheic athletes who undergo gynecological examination, it is important to appropriately evaluate whether the cause is low EA and to review exercise energy expenditure and energy intake. It remains difficult even for experts to calculate available energy using the ACSM definition formula when evaluating energy deficiency. Moreover, performing early FAT screening during teenage years and cooperation between the department of obstetrics and gynecology and sports dietitians are also issues. The aim of this paper is to review the management of FAT from the viewpoint of gynecologists.