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OR

THOPAEDIA:

SPOR

TS MEDICINE

Pr oduced by: THE CODMAN GR

OUP A 503C N

on-profit committed to enhancing medical education, patient care, and research through the pr

omotion of collaboration, the open exchange of data and content, and the transmission of knowledge across academic netw

orks.

Orthopaedia: Sports Medicine b

y CODMAN Group is licensed under a Creativ e Commons Attribution-NonCommercial-ShareAlike 4.0 International License, e xcept where otherwise noted.

CONTENTS

Series Introduction v

Preface vi

A W ord On Peer Review vii

List of Contributors ix

1. Stress F

ractures and the Female Athletic Triad 1

2. Burners and Stingers 8

3. Spondylolysis and Spondylolisthesis 16

4. Scapulothor

acic Disorders 23

5. Disorders of the Acromiocla

vicular Joint 28

6. Disorders of the Rotator Cuff 35

7. Adhesiv

e Capsulitis 43

8. Glenohumer

al Arthritis 50

9. Glenohumer

al Instability 58

10. Disorders of the Glenoid Labrum 66

11. Disorders of the Biceps and the T

riceps 72

12. Disorders of the Elbow Ligaments 78

13. Osteochondr

al Injuries of the Elbow 84

14. Epicondylitis of the Elbow 90

15. T

endon Disorders of the Hip and Thigh 96

16. Labr

al Tears of the Hip and Femoroacetabular Impingement 104

17. Disorders of the Extensor Mechanism of the Knee 114

18. Bursitis of the Knee 121

19. P

atellofemoral Disorders 127

20. Meniscus T

ears 136

21. Chondr

al Injuries of the Knee 144

22. Collater

al Ligament Injuries of the Knee 151

23. Cruciate Ligament Disorders 159

24. Achilles T

endon Disorders 167

25. Ankle Spr

ain 174

26. Cla

vicle Fractures 183

27. Pro

ximal Humerus Fractures 189

SERIES INTR

ODUCTION Orthopaedia is pr

oduced by The Codman Group (a 503C IRS-approved public charity) in collaboration with the U

nited States Bone and Joint Initiative and the Community of Musculoskeletal Educators. Orthopaedia aims

to serv

e as a free, up-to-date, peer-reviewed open educational resource for students and practitioners, thereby impr

oving the welfare of patients. Please visit http:// www.orthopaedia.com f

or the most current version of this text. At the website, you will also find its sister publications co

vering Hand and Foot & Ankle disorders, and others as they become available. Dan J acob Pr esident, The Codman Group J oseph Bernstein, MD, FACS S tephen J. Pinney, MD, MEd, FRCS(C) Christian V eillette, MD, FRCS(C) Orthopaedia Series Editors OR

THOPAEDIA:SPOR

TSMEDICINE v

PREF ACE The study of sports medicine is perhaps the most inter esting of the orthopaedic specialties. Within this field is the tr emendous hope of mankind: namely, to change the course of natural history. With every passing day, w e lose chondrocytes, osteocytes, and tenocytes to the ravages of wear and tear. U nlocking the mystery of cartilage, bone, and soft tissue r egeneration is the next frontier of orthopaedic science, and one in which the sports medicine p

hysician is thoroughly engaged. Through our evolving understanding of the biologic processes of the musculosk

eletal system, the sports medicine physician is constantly adherent to the adage, 'function f ollows form.' I

t is the field of sports medicine that took the moon shot in orthopaedics, namely, to re-create damaged anatom

y to its native state. F

rom the medical student perspective, the field of sports medicine is really where one should begin. While it is certainl

y intriguing to think of sports medicine as a specialty whose sole concern is getting athletes back to their craft, it is r

eally much more. The sports medicine physician is the true diagnostician of the musculoskeletal w

orld. If you had a musculoskeletal problem, but weren't sure where to go first, I'd say you should start with a sports medicine specialist.

As y

ou explore this volume covering the most common conditions that sports specialists treat, I hope you will see exactl

y what I mean. There is no part of the musculoskeletal system that isn't known to the sports medicine surgeon. W

hether it is the spine, foot and ankle, or shoulder, we've got it covered. This v

olume is our best attempt to make the information digestible, practical, easy to understand, and current. I

t should be where every medical student begins his or her journey in orthopaedics. There is no question that ther

e will be chapters here that will, sooner or later apply to you or someone you know. I t is for this reason that sports medicine is so r elevant, and key to any foundational knowledge in musculoskeletal disease. F otios Paul Tjoumakaris, MD Associate Pr ofessor, Orthopaedic Surgery S idney Kimmel College of Medicine, Thomas Jefferson University R othman Orthopaedic Institute Associate Dir ector, Sports Medicine Fellowship, Thomas Jefferson University Philadelp hia, PA vi OR

THOPAEDIA:SPOR

TSMEDICINE

A WORD ON PEER REVIEW

Ther

e is a great profusion of medical information available for free on the Internet, and a lot of it is good. Yet ev

en good information may not be completely useful to the reader who may not know if it is trustworthy. By contrast, ther

e is also a lot of medical information available for sale that is produced by well-known authors and organizations, though not al

ways for free. This volume aims to be both free and authoritative. T

o ensure medical accuracy, all of the material was reviewed by the section editors, who are of course content experts of gr

eat renown. In addition, each chapter was reviewed by an expert who was not involved in the cr

eation of the material. These reviewers were asked to read the chapter with one overriding goal in mind: to detect err

ors. The reviewers were then asked to "certify" the chapter as a reasonable presentation of the topic without an

y glaring mistakes in content. We are grateful to our reviewers, listed below: • Christop her Arena, MD reviewed Achilles Tendon Disorders. Dr . Arena is an Orthopaedic Surgeon affiliated with the P enn State Bone & Joint Institute. • N

icole Belkin, MD reviewed Disorders of the Collateral Ligaments and Cruciate Ligament Injuries of the Knee. Dr

. Belkin is an orthopaedic surgeon and sports medicine specialist at Columbia University. • J ames Carey, MD reviewed Meniscus Tears and Chondral Injuries of the Knee. Dr . Carey is an orthopaedic surgeon and sports medicine specialist at the U niversity of Pennsylvania. • Michael Castr o, DO reviewed Ankle Sprains. Dr. Castro is a Foot and Ankle Orthopaedic Surgeon at S ummit Orthopedics. • S teven Cohen, MD reviewed Disorders of the Elbow Ligaments and Osteochondral Injuries of the Elbo w. Dr . Cohen is an orthopaedic surgeon and sports medicine specialist at the Rothman Institute. • K evin Freedman, MD reviewed Patellofemoral Pain and Patellar Instability. Dr . Freedman is an orthopaedic surgeon and sports medicine specialist at the R othman Institute. • Sommer H ammoud, MD reviewed Adhesive Capsulitis and Glenohumeral Instability. Dr . Hammoud is an orthopaedic surgeon and sports medicine specialist at the R othman Institute. • P aul Juliano, MD reviewed Achilles Tendon Disorders. Dr Juliano is a Foot and Ankle Orthopaedic S

urgeon, Professor, Vice Chairman, Residency Director at Penn States Hershey Bone and Joint Institute. • Rahul Kapur

, MD reviewed Stress Fractures and the Female Athletic Triad. Dr Kapur is a famil y and sports medicine p hysician at the University of Minnesota. • J ohn D. Kelly IV, MD reviewed Scapulothoracic Disorders. Dr . Kelly is an orthopaedic surgeon and sports medicine specialist at the U niversity of Pennsylvania. • Andr

ew Kuntz, MD reviewed Epicondylitis of the Elbow. Dr. Kuntz is a fellowship trained shoulder and elbo

w surgeon at the University of PA. • Andr ew Milby, MD reviewed Burners and Stingers and Spondylolysis and Spondylolisthesis. Dr . Milby is a spine surgeon at Emory U niversity. • K evin O'Donnell, MD reviewed Disorders of the Rotator Cuff and Glenohumeral Arthritis. Dr . O'Donnell is an orthopaedic surgeon and sports medicine specialist in priv ate practice. • J ohn Salvo, MD reviewed Tendon Disorders of the Hip and Thigh and Labral Tears of the Hip and F emoroacetabular Impingement. Dr . Salvo is an orthopaedic surgeon and sports medicine specialist at the R othman Institute. OR

THOPAEDIA:SPOR

TSMEDICINE vii

• J

ohn Scolaro, MD reviewed Proximal Humerus Fractures and Clavicle Fractures. Dr. Scolaro is an orthopaedic traumatologist at the U

niversity of California, Irvine. • F otios Tjoumakaris, MD reviewed Disorders of the Biceps and Triceps. Dr. Tjoumakaris is an orthopaedic surgeon and sports medicine specialist at the R othman Institute. • B

radford Tucker, MD reviewed Disorders of the Extensor Mechanism. Dr. Tucker is an orthopaedic surgeon and sports medicine specialist at the R

othman Institute. • Pramod V

oleti, MD reviewed Disorders of the AC Joint and Bursitis of the Knee. Dr. Voleti is an orthopaedic surgeon and sports medicine specialist at the Albert Einstein College of M

edicine. • Miltiadis Z gonis, MD reviewed Disorders of the Glenoid Labrum. Dr. Zgonis is an orthopaedic surgeon and sports medicine specialist at the U niversity of Pennsylvania.

The material w

as also r eviewed by the f ollowing students fr om the P erelman School of Medicine at the U niversity of Pennsylvania: • Alexander Beschloss • J oshua T. B ram • O livia G. Cohen • Mitchell J ohnson • Ariana M eltzer-Bruhn • Anchi B. N umfor • S teven D. Tsai

A NECESSARY DISCLAIMER

P

eer-review notwithstanding, this being 21st century America, we must include the following Disclaimer, similar to those f

ound in works produced by well known authors and organizations. This material was pr epared for educational purposes only. We therefore disclaim any and all liability for any damages r

esulting to any individual which may arise out o f the use of the material presented here. We similarly disclaim r

esponsibility for any errors or omissions or for results obtained from the use of information contained here. This material is not intended to r

epresent the only, nor necessarily best, method or procedure appropriate for the medical situations discussed, but r

ather is intended to present an approach which may be helpful to others who face similar situations. W

e cannot can take any responsibility for the consequences following the application of any of the information pr

esented here. The inf ormation provided here cannot substitute for the advice of a medical professional. E ven if a given statement is completely true in the abstr act, it may not apply to a given patient. The inf ormation we offer is provided "as is" and without warranty of any kind. viii T

JOUMAKARIS

LIST OF CONTRIBUT

ORS CONTRIBUTING EDIT

ORS

The final v

ersion of this volume was produced by editing, r efining and merging material fr om individual contributions as w

ell as the material posted the OrthopaedicsOne wiki. The following authors listed below gener ously contributed to these raw chapters, and even more generously allowed their work to be edited, r efined and merged (according to the overall needs of the project).

Richard Campbell

Michele Car

avella Nick et Dedhia P atrick Donaghue Christopher Emerson

Ali Eternad-Rezaie

Michael Fisher

Christopher Hadle

y Sommer Hammoud MD

Thomas Hart

De van Higginbothamn Eoghan Hurle y Da vid Ivanov Zain Khazi Damm y Kolade Mark La wlor Christopher L ee K evin Lutsky, MD

Nathaniel Mercer

T revor Ottofaro Mili P arikh William Pham

Sudah Suleimen

Brian Thompson

Joseph T

racey Brian Winters MD

Barrett W

oods MD EDIT

ORIAL ASSIST

ANCE W

e are grateful for the expert editorial help provided by Megan Flinner, www.ManagedByMegan.com PHO

TOGRAPHY W

e thank P aul Tjoumakaris and Deonde Degennaro, ATC for demonstrating the physical examination maneuv

ers. CO

VER AR

T Co ver art designed and donated by: Louis C. O kafor, MD louisokaf or@gmail.com OR

THOPAEDIA:SPOR

TSMEDICINE ix

CHAPTER 1.

STRESS FRA

CTURES AND THE FEMALE A

THLETIC TRIAD

DESCRIPTION

The F

emale Athlete Triad was initially defined as the constellation of three interrelated clinical entities typicall

y f

ound in active young women: amenorrhea, osteoporosis, and disordered eating. The definition has now been br

oadened to recognize that each component of the triad exists on a spectrum. Thus, menstrual irregularities (

without amenorrhea), low bone mineral density ( without full-blown osteoporosis) and deficits of energy a

vailability due to a deficient nutrition (without a formal diagnosis of an eating disorder) may be sufficient to pr

ompt this diagnosis. Notably, the Triad can appear when there is not enough caloric intake to balance caloric expenditur

e, independent of whether that imbalance is intentional or unintentional. For example, many runners do not r

ealize how much to increase intake as they ramp up their training. The F

emale Athlete Triad can have significant medical ramifications outside of musculoskeletal medicine - notabl

y gynecological and psychological. Patients with the Female Athlete Triad usually come to attention of musculosk

eletal practitioners because of stress fractures: skeletal damage caused by repetitive loading forces that ex

ceed the bone's mechanical resiliency. The F

emale Athlete Triad is also relevant to musculoskeletal medicine in that even without a stress fracture, patients with this condition ma

y fail to attain an optimal peak bone mass in adolescence -the time of maximal bone f ormation- and thus p lace themselves at higher risk for osteoporosis later in life. STR

UCTURE AND FUNCTION

F

emale athletes, especially those who participate in an activity that values a thin physique, may choose to eat too little or ex

ercise too much. In the extreme, some may starve themselves (anorexia nervosa) or overeat and purge (bulimia

). Insufficient nutrition has tw o important consequences for bone health. For one thing, a calcium deficiency may be pr

esent. Also, decreased body fat is associated with decreased estrogen levels as well. Low estrogen can be r

ecognized by amenorrhea, but its deficiency can also cause clinically silent damage to the bone. Estrogen is a potent mediator of both osteoclast and osteoblast activity

. Without appropriate levels of this hormone, bone r emodeling is disrupted. Bone r

emodeling is the process that repairs the (micro)damage induced by regular activity. It also adjusts the bone'

s architecture to better withstand the mechanical stresses placed on it. R

emodeling is achieved through the coupled action of osteoclasts and osteoblasts. Osteoclasts resorb bone, and osteoblasts synthesize new bone matrix w

hich then becomes mineralized. A

ctivities that app ly cyclic loading f orces can lead to the formation of micr ofractures. (Running is the pr

ototypical "cyclic loading forces" activity but not the only one; rowing and throwing are commonly seen causes as w

ell.) When the rate of damage accumulation becomes greater than the rate of remodeling, these micr ofractures can lengthen and coalesce, resulting in a stress fracture. 1 OR

THOPAEDIA:SPOR

TSMEDICINE

P

ATIENT PRESENT

ATION P

atients with stress fractures will classically present with insidious onset of pain that acutely worsens with high impact activity and impr

oves with rest. Pain onset is often several weeks after a notable increase in a familiar p

hysical activity and is not associated with a specific injury. For example, a runner who recently increased her training fr

om 5 to 10 miles per day may present with new symptoms. An

y female athlete w ho presents with a stress fracture should be questioned f or the pr esence of factors associated with the F

emale Athlete Triad. The patient should first be asked about activities and nutrition. As a first appr

oximation, athletes should eat about 45 kCal per Kg of lean body mass, in addition to the sports-specific energy demands (

e.g., approximately 100 kCal for every mile ran). In addition, they should be asked about their menstrual history and use of birth contr

ol pills. A history of prior str ess fractures, weight changes or other diseases that ma y affect bone health (e.g., thyroid disease) should also be reviewed. The first p

hysical finding to assess is the body mass index (BMI). BMI is defined as the body mass divided by the squar

e of the body height. Because self-reporting is imprecise, formal measurement should be made. According to the 2014 F

emale Athlete Triad Coalition Consensus Statement, a BMI below 18.5 k g/m2 r epresents moderate risk and a B

MI below 17.5 kg/m2 is high risk.

On p

hysical exam, stress fractures often have no objective findings at all. Point tenderness or swelling may or ma

y not be present. If there is a high index of suspicion, a thorough exam of the implicated bone is warranted. The 3-point fulcrum test is useful in identifying f

emoral shaft stress fractures and is considered positive if pain is elicited. A

dditionally, a calcaneal squeeze test that elicits pain can indicate a calcaneal stress fracture of the f

oot (See Figure 1). Figur e 1: Squeezing calcaneus side to side may reveal a stress fracture.

Soft, thin hair on the extr

emities (so-called "lanugo"), scarred knuckles, and parotid gland enlargement are p

hysical exam findings seen in patients with anorexia or bulimia nervosa. Bradycardia and low blood pressure can be signs of malnutrition or lo

w energy availability, but this is difficult to differentiate from a physically fit athlete with a slo

w baseline resting heart rate. OR

THOPAEDIA:SPOR

TSMEDICINE 2

OBJECTIVE EVIDENCE

In F

emale Athlete Triad, each of the three components can be assessed independently, which can help guide tr

eatment. In low energy availability states, electrolyte abnormalities such as hypokalemia, hyponatremia, or an acid-base disturbance ma

y be present. M

enstrual disturbances should first be assessed with a urine pregnancy test. Other lab values can provide insight on the functioning of the h

ypothalamic pituitary adrenal axis including luteinizing hormone (LH) and follicle-stimulating hormone, pr

olactin, and thyroid stimulating hormone (TSH). Assessing bone mineral density with dual -energy x-ray absorptiometry (D EXA) is criticall y important f or patients with F

emale Athlete Triad, especially if she has already had a stress fracture. A Z-score less than +1.0 in a y

oung athlete should prompt further evaluation because bone mineral density is expected to be higher in those w

ho regularly participate in weight-bearing activity. T

ypically, patients with stress fractures will have normal radiographic findings. Positive findings are more likely to be f

ound several weeks after symptom onset. These findings include cortical radiolucency, periosteal reaction (

see Figure 2), endosteal or cortical thickening, and (in the rare case) a fracture line. Figur

e 2: Stress fracture of 2nd metatarsal identiified by the surrounding periosteal reaction. (Case courtesy of Dr. Vikas Shah, rID 62575, Radiopaedia.org)

MRI and technetium bone scans ar

e the best diagnostic imaging tests for identifying occult stress fractures (see F

igure 3). T1 and T2-weighted MRIs will pick up marrow edema and delineate clear fracture lines. Tc99m bone scan will sho

w focal uptake at the stress fracture site. 3 T

JOUMAKARIS

Figur

e 3: Stress fracture of distal tibia. Radiograph on left shows a subtle area of sclerosis whereas the T1-weighted MRI on the right clearly demonstrates K?<@E:FDGC ,8;@FG8<;@8FI> @>LI

EPIDEMIOL

OGY F emale Athlete Triad is most commonly seen in adolescents and y oung adults. Sports in which a thin figure and light w

eight are competitively advantageous, such as ballet, cheerleading, gymnastics, and cross-country running, ar

e often implicated. Athletes of any sport can develop the condition. A

ccording to the American Academy of Pediatrics, it is difficult to estimate the true prevalence of the triad as each of the components ma

y be expressed in v arying severity. Moreover, not all components are present simultaneousl

y. Beyond that, prevalence is assessed by self-reported (and possibly imprecise) metrics in cross-sectional studies. W

ith that caveat, the frequently used approximation is that 1% of high school athletes have all thr ee components and that the prevalence of at least one component may be as high 50%. I

t is also difficult to estimate the true prevalence of stress fractures, primarily because many cases do not present f

or medical attention. Also, among those fractures that are seen, treatment (in the form of relative rest) is often initiated empirically without objectiv

e confirmation. Stress fractures are most commonly seen in weight bearing bones of the leg ( e.g. the metatarsals and calcaneus most commonly). They can also occur in the tibia, OR

THOPAEDIA:SPOR

TSMEDICINE 4

fibula, na vicular, femur and bones of the upper body. Young military recruits are another population where str

ess fractures are commonly identified, especially within the first several months of their training. In this population these injuries ar

e often called "March Fractures," and classically occur in the 2nd metatarsal.

DIFFERENTIAL DIA

GNOSIS Lo

wer extremity pain in an athlete without a history of overt injury suggests the diagnosis of stress fracture, but this ma

y also be the presentation of a simple muscle strain. Pain that does not get better with rest may suggest mor

e serious conditions such as bone tumors or infection. Radiograp hs in patients with suspicious symptoms ar

e essential. Because the x-ray presentation of stress fractures, tumors, and infections can be similar, MRI or

other adv anced testing may be needed as well.

RED FLA

GS A diagnosis of F

emale Athlete Triad should be high on the differential when any of the following are present: • An

y female athlete that presents with a stress fracture, • Body mass index belo w 20, • O ligomenorrhea or amenorrhea in a competitive athlete, • Concerning comments about w eight gain, weight loss, calorie restriction, or body image. Ther

e should be a high index of suspicion for a stress fracture when any of the following are present: • An athlete w

ho presents with pain in the lower extremity without a clear history of an injury, • History of dramatic incr

ease in a specific physical activity, • A cutely worsening and localizing pain with exercise and significant relief with rest. The F

emale Athlete Triad is itself a "red-flag" for the presence of other conditions that may be beyond the expertise of a musculosk

eletal medicine specialist. These include gynecological abnormalities, endocrine disor

ders (e.g. polycystic ovary syndrome, hyper/hypothyroidism), complications of p harmaceuticals (both pr

escribed and illicit), and psychological disorders. It is critical to make the appropriate referral to a provider with the r

elevant expertise. S

tress fracture of the superior femoral neck (the so-called "tension side" of the neck) can propagate and displace the f

emoral head from the shaft. (This contrasts with such fractures on the inferior neck, the "compression side" (

see Figure 5), which, should they propagate, will collapse upon themselves.) In turn, such disp lacement ma

y disrupt the blood supply to the femoral head and cause osteonecrosis. This is a rare complication of a rar

e condition, but the consequences of missing it can be catastrophic. Thus, a presentation suggesting a stress fractur

e of the hip demands diligent attention, prompt imaging and referral to an orthopaedic surgeon if the diagnosis is confirmed.

5 T

JOUMAKARIS

Figur

e 5: MRI showing stress fracture of the inferior femoral neck with surrounding edema. (Courtesy of https://radiopaedia.org/cases/=

8CE<:BJKI TREA

TMENT OPTIONS AND OUT

COMES The primary goal in tr

eating Female Athlete Triad is restoring energy balance, which will help restore menstrual r

egularity and improve bone mineral density. Nutrition education, modifying diet and physical activity, and partnering with mental health services ar

e important methods in treating energy availability. Calcium and vitamin D supp lementations are also important in r estoring bone health. Contrary to r

ecommendations for the older population, bisp hosphonates are not r ecommended in tr eating low bone mineral density or osteopor

osis in patients with Female Athlete Triad, as their use increases the risk of stress fractur es. The tr

eatment goal for Female Athlete Triad is restoring energy balance and improving bone mineral density. Clinical success can be gauged b

y weight gain and resumption of menses. Screening and early diagnosis of this condition is essential as bone loss during adolescence and earl

y adulthood is not recoverable and impacts the patient' s peak bone mineral density later in life. The mainsta

y of treatment of stress fractures is rest and avoidance. Activity is restricted, and athletes cannot r

eturn to play until pain subsides, tenderness has resolved, and radiographic findings are negative. S

tress fractures of metatarsals, femoral shaft, and tibial shaft can generally be managed with modified weight bearing. F

ractures in the calcaneus and navicular may require a stricter non-weight bearing status. Open r

eduction and internal fixation (ORIF) may be considered in elite or professional athletes who require a faster r

ecovery and are at high risk of complications, such as displacement or nonunion. Operativ

e treatment is also indicated for fractures in locations at high risk of fracture propagation or poor healing, such as on the tension side of the f

emoral neck or on the anterior cortex of tibia. Surgery is also indicated w hen non-operative measures have failed. OR

THOPAEDIA:SPOR

TSMEDICINE 6

P

ersistent weight bearing on a stress fracture may cause arrest of bone healing or lead to a complete fracture, incr

easing the risk of displacement and nonunion. Stress fractures have an overall excellent prognosis when tr

eated appropriately (operative vs non-operative, non-weight bearing vs modified weight bearing) and the patient is educated on p

hysical activity modification.

RISK F

ACTORS AND PREVENTION

P

articipation in sports that place value on thinness, either for esthetic reasons (e.g. gymnastics) or performance (

e.g. long-distance running) may increase the risk of developing the Female Athlete Triad. Another risk factor is p

laying a sport in which athletes compete in weight divisions (e.g. light-weight rowing). Lack of nutritional education in a competitiv

e athlete is also a known risk factor. Pr

evention of the Female Athlete Triad may be helped by screening and early recognition. Screening can be accomp

lished during sports physicals with questionnaires or through targeted history-taking. Information such as menstrual history

, dietary habits, body image assessment, and eating behaviors can identify females at risk and aid in the diagnosis if F

emale Athlete Triad is already present. A

thletes with a sudden increase in their level of activity are at risk for stress fracture: the process of bone r

emodeling is overwhelmed. This can be mitigated by well-conceived training schedule.

MISCELLANY

The F

emale Athlete Triad is typically not denoted by the acronym FAT-perhaps because the syndrome is characterized b

y a lack of fat.

KEY TERMS

F

emale Athlete Triad, stress fractures, low energy availability, amenorrhea, bone mineral density, osteoporosis, insufficiency fractur

es, march fractures, bone remodeling

SKILLS

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