Working Diagnosis:
Gelatinous transformation of bone marrow (GTBM) secondary to severe malnutrition

Treatment:
There is little literature about gelatinous transformation of bone marrow and return to play guidelines. We recommended a multidisciplinary medical team approach with a goal of ultimately increasing energy availability.

Outcome:
Fortunately, when gelatinous transformation of bone marrow occurs secondarily to malnutrition, it is thought to be reversible and not have any lasting sequela. In terms of exercise, our patient followed a gradual return to exercise protocol lead by a physical therapist. She was also educated about her increased risk of stress fractures if she continued to overexert herself while she had gelatinous transformation of bone marrow. Of note, during follow up she was found to have a stress fracture of the bilateral inferior sacrum.

Author's Comments:
This patient presents with several risk factors for female athlete triad, a syndrome characterized by low energy availability, menstrual dysfunction, and low bone density. This low energy availability can be secondary to decreased caloric intake and/or increased energy expenditure. Her history of decreased caloric intake, abrupt increase in running mileage, and personal history of a stress fracture in high school, are all risk factors for the female athlete triad. In this patient's case, malnutrition manifests as gelatinous transformation of the bone, a rare yet associated pathology of disordered eating. As a reversible disorder, a patient with gelatinous transformation of bone marrow should be counseled on the important returning to appropriate energy intake as the increased risks of fractures associated with this condition.

Editor's Comments:
The female athlete triad can be defined as low energy availability, which can occur with or without an associated eating disorder, menstrual dysfunction or irregularity and an altered bone mineral density. Low energy availability is the key disorder among the triad, and often the first to be noted by a clinician. While return to play protocols exist for the female athlete triad, few if any return to play protocols exist for the sequela of gelatinous transformation of the bone.

References:
1. De Souza, MJ, Nattiv, A, et al. 2014 Female Athlete Triad Coalition Consensus Statement on Treatment and Return to Play of the Female Athlete Triad: 1st International Conference. San Francisco, CA 2012. Br J Sports Med 2014.
2. Rafiullah et al. Gelatinous Bone Marrow Transformation Secondary to Unusual Eating Habits and Drastic Weight Loss. BMJ Case Reports (2013)
3. Shergill, KK, Shergill, SG, et al. Gelatinous Transformation of Bone Marrow: Rare or Underdiagnosed? Autopsy & Case Reports (2017): 7(4).
4. Williams NI, Statuta SM, et al. Female Athlete Triad: Future Directions for Energy Availability and Eating Disorder Research and Practice. Clinical Sports Medicine. 2017 36(4).

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