Topic:  Stress Fractures

Presenter:  Dr. Jacqueline Corkum

Date:  Tuesday, February 7, 2017

Time: 18:00

Location:  Goldring Centre Room 221

Relative Energy Deficiency in Sport (RED-S)

  • Syndrome that affects physiological function, health and athletic performance
  • Etiology: Relative energy deficiency (Dietary energy intake < energy expenditure)
  • Affects females and males
  • Prevalence in adult elite athletes: Females 20%, Males 8%
  • Low energy availability independent factor in poor bone health and indirect factor by causing menstrual irregularities which are associated with poor bone health
  • Screening for RED-S
    • Investigating those at high risk
      • Brief eating disorder in athletes questionnaire (BEDA Q)
      • Menstrual history
      • Bone health: BMD if >6mon of decreased energy availability, disordered eating or amenorrhea
    • Annual athlete screening
  • Treatment of RED-S (IOC 2014 consensus statement)
    • Goal: ↑ energy availability by ↑ energy intake, ↓ energy expenditure or both
    • Practical approach
      • ↑ energy intake: ↑ by 300-400 kcal/day
      • Reduce level or add rest day in training regimen
    • Bone health:
      • Calcium 1500mg, Vit D 1500-2000IU (to keep VitD > 32-50ng/mL)
      • Females: Recommend against OCP, bisphosphonates, SERM, PTH, cacitonin
      • Males: Testosterone (hypogonadism), bisphosphonates.

Article 1: Tenforde AS, Carlson JL, Chang A, Sainani KL, Shultz R, Kim JH, et al. Association of the Female Athlete Triad Risk Assessment Stratification to the Development of Bone Stress Injuries in Collegiate Athletes. American Journal of Sports Medicine. 2016;1–9.

  • 29% collegiate athletes (NCAA) identified as moderate or high risk of having female athlete triad (higher in sports emphasizing leanness)
  • Higher risk categories had ↑ risk of sustaining a subsequent bone stress injury
  • Cumulative risk score may help identify athletes at increased risk for BSIs

Stress fracture treatment

  • Protection/Activity modifications depends on risk of non-union or fracture propagation
    • Low risk of complications: MT2-4 shafts, posteromedial tibial shaft
    • High risk: Anterior cortex tibia, patella, femoral head, superior side femoral neck, medial malleolus, talus, navicular, proximal MT4-5, base MT2, great toe sesamoids, pars
  • Address energy balance issues now
  • Vit D, calcium
  • Bone stimulator
    • Pulsed ultrasound bone stimulator
    • Electromagnetic stimulator
    • Evidence for bone stimulators in acute fractures may not be relevant in stress fractures because acute fractures heal with endochondral ossification vs stress fractures with intramembranous bone healing

Article # 2: Beck BR, Matheson GO, Bergman G, Norling T, Fredericson M, Hoffman AR, et al. Do Capacitively Coupled Electric Fields Accelerate Tibial Stress Fracture Healing?: A Randomized Controlled Trial. Am J Sports Med. 2008;36(3):545–53.

  • Electrical bone stimulator did not accelerate tibial stress fracture healing in primary between group comparisons
  • Some evidence in decreased time to healing for:
    • High compliance with stimulator
    • High rest compliance
    • Stimulator for more severe injuries (not statistically significant)

 Author:  Dr. Jacquelyn Corkum (Feb 7, 2017 PR ND)


  • Brukner, P. and Khan, K. (2012). Clinical Sports Medicine.
  • De Souza MJ, Nattiv A, Joy E, Misra M, Williams NI, Mallinson RJ, et al. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference Held in San Francisco, CA, May 2012, and 2nd International Conference Held in Indianapolis, IN, May 2013. Clin J Sport Med. 2014;24(2):96–119
  • Mountjoy M, Sundgot-Borgen J, Burke L, Carter S, Constantini N, Lebrun C, et al. The IOC consensus statement: beyond the Female Athlete Triad–Relative Energy Deficiency in Sport (RED-S). Br J Sports Med. 2014;48(7):491–7.