Working Diagnosis:
Right sided sacral alar stress fracture.
Low bone mineral density.

Treatment:
The athlete's treatment plan followed a multifaceted approach. She is in the process of being treated with twice daily vitamin D 2,000U and calcium carbonate 500mg supplementation for eight weeks. Her weight and nutrition have been cautiously monitored by our consulting nutritionist with the goal of creating a positive energy balance. A clinical psychologist was consulted for evaluation of her perseveration on exercise. The athlete was restricted to a period of six weeks of pain free, low impact activity before slowly returning to running activity.

Outcome:
The athlete has been able to maintain a positive energy balance as she has gained five pounds since the onset of her hip pain. She continues to follow up with clinical psychology once weekly for cognitive behavioral therapy. She is currently pain free and has started a gradual return to running activity.

After undergoing a period of six weeks of pain free, low impact cross training, the athlete has progressed to three times weekly light running on alternating days at twenty five percent of her preinjury total weekly mileage and fifty percent of her typical preinjury pace. Progression to complete return to running activity will continue to be granted slowly at about ten percent weekly increments if the athlete remains pain free, maintains a positive energy balance including stable body weight, and continues to be compliant with cognitive behavioral therapy.

Author's Comments:
Injuries can have a profound effect on the mental health of an athlete with some athletes restricting their caloric intake because they feel they don't deserve to eat, or feel that they will gain excessive weight without their sport. In the case of this patient, it was extremely important that a multidisciplinary approach be taken with a nutritionist and clinical psychologist monitoring the patient closely for disordered eating. In addition, further evaluation into the patient's menstruation is indicated as she was found to have decreased bone density during her workup, and she competes in cross country running, a sport known to be a risk factor for Female Athlete Triad as it emphasizes leanness and endurance. Female Athlete Triad is a condition of female athletes that refers to disordered eating, functional hypothalamic amenorrhea, and osteoporosis. The condition is a manifestation of the interrelationship of energy availability, menstrual function and bone mineral density.

References:
Hainline B. Breaking Barriers to Mental Health. AMSSM 2015 Conference.

Logan K. Female Athlete Triad. In: The 5-Minute Sports Medicine Consult. 2nd ed.Philadelphia,PA: Lippincott Williams & Wilkins, 2011:158-159.

Acknowledgments:
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