The following essays are extracts of monthly articles written for the Syracuse Track Club newsletter by Dr. Dan Wnorowski.
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Female Athletic Triad



From Morton’s Neuroma to High Tech Medicine, or Do You Really Have to Spend $1,000 to Find the Lump?

After I wrote last month’s gem regarding Morton’s neuroma, I was surprised to see an interesting two-page article on page 38 of the October issue of Runner’s World entitled “Morton’s Neuroma”, by Marlene Cimons. This was pure coincidence, I assure you. Actually, I believe she did an excellent job describing the problem from the layperson’s perspective. This gave me an idea for a complementary column, wherein an injured runner can describe their symptoms, and tell their story as an intro to discussion of interesting and common medical conditions, hopefully with the goal of prevention or at least early intervention. I am sure that all of you have many interesting tales of woe that you might like to share with fellow STC readers. Anyway, I digress; more on this later.

She insightfully outlines the condition, cause and prevention, diagnosis, treatment, and cure. Under diagnosis she writes: “An MRI can find a neuroma, but MRI’s are rarely used because they’re so expensive. In recent years, however, a very small number of radiologists have become adept at using ultrasound to find a neuroma. This can be especially valuable in determining its exact location.” Although these statements are true, such widely read commentary (even if written with good intentions) creates huge practical problems for doctors and other providers. Morton’s neuroma is typically an easy clinical diagnosis. This means that after listening to the patient’s complaints, asking some pointed questions, and performing a physical exam, there is sufficient information to substantiate labeling the problem as “Morton’s neuroma”. This diagnosis is straightforward and simple, and from there, one can easily discuss treatment options.

I cannot think of any good reason why one would even consider ordering a MRI for this problem. MRI remains extraordinarily expensive, relative to the cost of clinical diagnosis. The writer’s mere mention of this option however, opens the door for patients to request that their doctors order a MRI for evaluation of foot pain (or any other problem, for that matter). “…But it said in the article that an MRI can find a neuroma…how can you be sure I have one?” People often have to see it to believe it. I find myself constantly explaining why we don’t need a MRI for one’s complaint.

In general, many will want to get the test, especially if someone else, namely the insurance company, will pay for it. We cannot order MRI studies for every orthopedic problem without the risk of bankrupting the system. Health care professionals, especially specialists, spend years and years training to recognize problems by their presentation, and become exceedingly skilled at doing so, without MRI back-up. Furthermore, MRI studies are only as good as the hardware and software, and the experience of the interpreting radiologist. They are not always accurate, despite the price tag.

Finally, she mentions ultrasound, “…a very small number of radiologists have become adept at finding a neuroma. This can be especially valuable in determining its exact location.” That is true, especially the part about “a very small number”. This is a test that can be done in select areas of the country where it has been well-developed. But the same argument applies. You don’t need this test to find a Morton’s neuroma. They cannot hide. There is only one location. The clinical diagnosis is sufficient. If your doctor needs a test to “find the exact location” of a Morton’s neuroma, you better get a new doctor, especially if surgery is being considered.

The risk here is more than wasting money and contributing to the spiraling rise in health care cost. The real risk is the potential for obsolescence of medical diagnosis based upon clinical skills. If patients become convinced that all you need to do to find the problem is “get a picture”, and if this becomes the standard of care, what’s the point in listening to the patient and examining the foot? The cost of a specialist evaluation for a running related foot problem is a very small fraction of the cost of a MRI. Attached to the ears listening to your story and the hands evaluating your foot is a brain with a wealth of personal experience. Don’t trade the brain for the picture.

Dan Wnorowski, M.D.

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10 Take Home Points: “The Female Athletic Triad”

1- The Female Athletic Triad is not rare. It is composed of disordered eating, amenorrhea (missed menstrual periods), and osteoporosis (loss of bone density). It is most often seen in achievement-focused athletes, participating in sports where weight and body image are traditionally tied to performance: running, dance, gymnastics, figure skating, diving, cheerleading, weight calss sports, etc.

2- Simply, the Triad is caused by inadequate caloric intake and/or caloric consumption for the needs of athletic activity, training and competition. This causes a shutdown of normal female endocrine function and reduced estrogen production, in part through the decline of body fat, and hence, a loss of ovulation and menstrual function. Loss of estrogen reduces bone mineralization.

3- The incidence of severe eating disorders (anorexia and bulemia) in the general female population in the U.S. is 3-5%, but much higher in athletic women (as high as 15 to 62%). Females make up 90% of those with eating disorders, which means that 10% are males (e.g.- wrestlers).

4- A definition of an eating disorder includes: caloric restriction or elimination +/- compulsive overeating behaviors (dieting, bingeing, purging, and exercising) stemming from an abnormal focus on performance, body image and body weight.

5- The implications of loss of menstrual function, even temporarily, before age 30 are very serious. The loss of estrogen causes a permanent and life-long loss of bone mineral which cannot be replaced. Remember, 60-70% of female skeletal calcium is stored before age 28. Athletic amenorrhea (loss of menses)= loss of estrogen= loss of bone. One cannot regain this lost bone, only reduce the rate of further loss! The bone that is not deposited before age 30 cannot be deposited later in a catch-up fashion! Athletic amenorrhea is essentially a pre-menopausal menopause!

6- The weakened skeleton is prone to fracture (especially stress fracture). This may be the first sign of the Female Athletic Triad. Stress fractures that occur without obvious training errors and/or mechanical problems signal the possibility of the Female Athletic Triad. The bone of those affected is 4.5x more likely to fracture than those without this condition.

7- Recurrent soft tissue and overuse injuries also may suggest eating disorders, as one can view excessive or compulsive exercise (to the extent of injury) as an extreme method of weight control.

8- Symptoms and signs of the Triad, apart from loss of menstrual function and orthopedic injury include: excessive focus on body weight/image/dieting despite thin/normal habitus, bingeing/purging,use of diuretics/laxatives, poor physical/mental and athletic performance, loss of attention/concentration, depression, fatique, cold intolerance, fainting/dizziness, brittle nails/hair, sore throat, bloodshot eyes, abdominal pain/constipation/bloating, swollen face or extremities, etc.

9- It is very doubtful the those affected with this condition will overcome the denial that often accompanies the Triad, and ask for help, especially if positively reinforced by athletic success. Suspicion and compassion on the part of family, friends, teammates, coaches, athletic trainers, teachers, and health care professionals is necessary, coupled with the willingness to assist in getting help for this individual. Rememeber, anorexia is fatal in 14%! Get help and enlist a team approach: ask your trainer, nurse, primary care provider, orthopedic surgeon, nutritionist, or gynecologist.

10- The most common cause of amenorrhea is pregnancy.

For more information and some helpful references, go to the Female Athletic Triad.

Dan Wnorowski, M.D.

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