1. Counsel patients about adequate calcium and vitamin D intake.

2. Assess osteoporotic and fracture risk in patients, based on history and risk factors.

3. Describe available medications for treatment of osteoporosis.

4. Identify anterior cruciate ligament and patellofemoral pain, based on physical examination and clinical findings.

5. Recognize stress fractures based on patient history and clinical findings.

Osteoporosis: Diagnosis and Management
Veronica K. Piziak, MD, PhD, Professor of Medicine and Endocrinology, Texas A&M University Health Science Center College of Medicine, and Director, Division of Endocrinology, Scott & White Healthcare, Temple, TX

Calcium: among US Navy recruits who were given 2000 mg/day of calcium carbonate and 800 IU/day of vitamin D, rate of stress fracture 5.3% (vs 6.6% in placebo group); 1200 mg/day recommended for premenopausal women, 1200 to 1500 mg/day for postmenopausal women; calcium and vitamin D supplementation recommended for runners; adequate calcium and vitamin D levels in women 8 to 10 yr postmenopause shown to preserve bone mineral density (BMD); in perimenopausal women, calcium less effective, due to loss of estrogen; acid necessary to dissolve calcium carbonate supplements; patients taking proton pump inhibitor (eg, omeprazole [Prilosec OTC]) need another source of calcium (eg, dietary calcium, calcium phosphate) rather than calcium carbonate; dietary calcium supplements usually calcium citrate or calcium lactate; Viactiv chewable calcium supplement contains vitamin K (use with caution in patients taking warfarin [Coumadin])

Vitamin D: may prevent falls; may improve fibromyalgia; vitamin D3 found in oily fish and cod liver oil; vitamin D2 found in yeast, plants, and most vitamin D supplements; vitamin D2 less expensive and 30% as potent as vitamin D3 , but effective in replacing vitamin D stores; increases phosphorus and calcium absorption; helps mineralize bone; helps regulate bone turnover

Vitamin D deficiency: measure 25-hydroxyvitamin D level (when <30 ng/mL, parathyroid hormone [PTH] chronically elevated, leading to loss of hip BMD); aim for 30 to 40 ng/mL; toxicity at 80 to 85 ng/mL; calcium absorption increases until level reaches 50 to 60 ng/mL; of 1536 community-dwelling women who received therapy for osteopenia and/or osteoporosis, 52% had osteomalacia (medications for osteoporosis do not treat osteomalacia; >400 IU/day of vitamin D recommended); new recommendations, 800 to 1000 IU/day; for patients with personal or family history of renal stones, individualize vitamin D therapy; vitamin D replacement—start with 1000 IU/day and recheck levels; for significant deficiency (<20 ng/mL), give 50,000 IU of vitamin D2 once weekly for 8 to 12 wk; if patient develops nausea, give 50,000 IU once monthly for 5 to 6 mo; in chronic renal disease, treating vitamin D deficiency lengthens lifespan; in older patients with renal insufficiency, consider increasing vitamin D and reducing elemental calcium supplementation to 1000 to 1200 mg/day (to prevent calcification in, eg, arterial system)

Osteoporosis: bone changes with aging—loss of trabeculae; development of holes in bone; shrinkage of cortex; enlargement of marrow cavity; bone remodeling—“you don’t want this bone turning over too much or too fast”; patients with calcium or vitamin D deficiency remodel poorly and have poor bone quality; important to slow remodeling in high-risk patients (eg, patients on steroid therapy, perimenopausal women)

Fractures: 1 in 5 patients with hip fracture dies within 5 yr; 1-yr mortality after pelvic fracture, 14% (make sure patients on calcium, vitamin D, and bone-active agent); patients with osteoporosis (T score -2.5) and prone to fracture should be treated; most fractures occur in patients with osteopenia; National Osteoporosis Foundation guidelines for treatment of osteoporosis (ie, based only on T scores) cost-effective; suggests appropriate to treat patients with T score of -1.5 in presence of risk factors; treating patients with T scores of -2.0 in absence of risk factors controversial; patients with T scores of -2.5 and no risk factors should be treated; FRAX tool—World Health Organization (WHO) fracture risk assessment tool; input patient’s ethnicity, age, sex, weight, height, history of fracture, and parental history; can input patient’s T score or body mass index (BMI); predicts risk for osteoporotic and hip fracture over next 10 yr; new guidelines—initiate treatment in men and women ≥50 yr of age with history of hip or vertebral fracture, 1 previous fracture and low bone mass, low bone mass and secondary causes (eg, steroid use), and low bone mass with 10-yr hip fracture probability ≥3% or 10-yr probability of major osteoporosis-related fracture probability of >20%

Raloxifene: useful in patients at high risk for breast cancer; “not the best thing for osteoporosis”; can be used in combination with bisphosphonate; no proven efficacy in hip fracture

Bisphosphonates: drug class of choice for established osteoporosis; patients must continue calcium and vitamin D supplementation; alendronate—approved for prevention and therapy for osteoporosis and steroid-induced osteoporosis; 70 mg/wk; preparation containing vitamin D available, but often not approved by insurance companies (may be expensive); generic formulation available (side effects [eg, heartburn] may occur; according to speaker, “most people seem to tolerate it pretty well”); risedronate—regimen of 150 mg once monthly approved by Food and Drug Administration (FDA); BMD accrual comparable to 5-mg daily tablet with same side-effect profile (eg, chills and aching during first month of use); minimum 30-min wait before eating; ibandronate (Boniva)—150 mg/mo; minimum 60-min wait before eating for optimal BMD accrual; BMD accrual of 150 mg/mo comparable to 70 mg/wk of alendronate (Fosamax)

Intravenous (IV) bisphosphonates: IV ibandronate—check for coverage by Medicare; few side effects; 15-sec IV push; stored at room temperature; 3 mg every 3 mo; appropriate for patients who cannot tolerate oral bisphosphonates due to gastrointestinal side effects (eg, dyspepsia); zoledronic acid (eg, Reclast)—approved for once-yearly use; 15-min IV infusion; side effects include shaking, chills, headaches, and muscle aches (to avoid renal insufficiency, inform patients to take acetaminophen [eg, Tylenol] rather than nonsteroidal anti-inflammatory drug [NSAID]); contraindicated in pregnancy and in patients with creatinine clearance <35 mL/min; check creatinine level before giving IV bisphosphonate; make sure patients taking adequate calcium and well hydrated; associated with atrial fibrillation (may not be cause-and-effect; changing prescribing patterns not recommended) and osteonecrosis of jaw (rare; consider stopping for 4-5 wk before patient undergoes dental work)

Changes in BMD: risedronate—increases volume of trabecular bone; decreases trabecular separation; statistically significant decrease in vertebral fractures within 6 mo (8-9 mo for alendronate); loss of BMD began within following year in patients who discontinued therapy after taking 5 mg/day for 3 yr; however, BMD loss not as rapid as BMD accrual; Fracture Intervention Trial (FIT) Long-Term Extension Trial (FLEX)—when alendronate stopped after 5 yr, spinal BMD begins to decrease, but “the slope isn’t the same” (ie, efficacy remains after stopping drug; gradually declines over several years); use for 10 yr safe; study saw no osteonecrosis of jaw, no oversuppression of bone, and no increase in overall fracture rate; when BMD normalizes, drug can be discontinued (monitor patients; if bone loss >5% of baseline, restart therapy); do not stop therapy after 5 yr in patients with history of fracture and low BMD (T score -1.5)

Teriparatide (PTH; Forteo): directly builds bone rather than stopping bone resorption; use of intermittent PTH daily (with adequate calcium) increases BMD by ≈5% yearly (BMD accrual lower if bisphosphonate used before); in patients with severe osteoporosis, consider as first-line therapy; rapid loss of BMD accrual seen after discontinuation (begin bisphosphonate therapy immediately to maintain BMD)

Receptor activator of nuclear factor êâ (RANK) ligand: osteoclasts help replace bone and protect bone from microfractures by eroding bone surface; as person ages, osteoblasts (bone-forming cells) fail to “fill this hole”; in bone repair, osteoblasts signal macrophagic osteoclast precursor cells to produce receptors for RANK ligand; RANK ligand makes osteoclasts become bone-destroying cells; in postmenopausal osteoporosis, RANK ligand produced in excess; denosumab—monoclonal antibody to RANK ligand; reduces number of active osteoclasts; recommended dose, 60 mg subcutaneously every 6 mo; virtually no side effects; BMD accrual comparable to that with alendronate; data suggest spinal BMD accrual over 2 yr, 6.5% (at 4 yr, 10%; better than alendronate; nearly as good as teriparatide), and hip BMD accrual, 3.4%; increases cortical bone

Common Athletic Injuries in Women
Scott Paluska, MD, Clinical Associate Professor of Medicine, University of Illinois at Urbana-Champaign, College of Medicine, and Medical Director, Oak Orthopedics, Urbana, IL

Biomechanic issues in women that contribute to lower-extremity injuries: wider pelvis; tendency for femoral anteversion (head of femur rotates inward; greater internal rotation of femur affects knee); women with narrow “notch” (groove in center of femoral condyle) may have smaller ligament or increased risk for larger ligament banging against bones of notch; external tibial torsion (lower leg rotates outward; affects knee); muscle imbalance (eg, quadriceps stronger than hamstrings; quadriceps pull tibia too far forward); hyperextension or increased flexibility around knee can stress biomechanical restraints and alter motion of knee; tendency for genu valgum (knock-knee)

Diagnosis of anterior cruciate ligament (ACL) injury: according to some studies, risk 8 times greater in women than in men; risks involve sports that involve cutting, jumping, and direction changes; often noncontact injuries; history and presentation—patients often hear or feel “pop"; sense of impending doom (“they know that something is wrong”); immediate (in ≤1 hr) swelling (meniscal tears swell 24-48 hr later); inability to bear weight; joint line tenderness; decreased motion; anterior drawer test—while patient’s knee flexed 90º, foot stabilized and anterior force applied to proximal tibia to see how much it moves; translation graded from 1 to 3 (1, “it didn’t really move that much”; 2, “it moved some”; 3, “it moved a fair amount”); Lachman’s test—recommended; while patient’s knee flexed 30º to 35º, stabilize femur with one hand while firmly grasping tibia with other hand; pull tibia forward and grade amount of movement; requires relaxation of hamstring; compare to uninvolved knee; x-rays—may show tibial or femoral spine avulsion; Segond fracture (pathognomonic; lateral capsular avulsion fracture); magnetic resonance imaging (MRI)—helpful when concomitant injuries suspected; helps diagnose or confirm ACL tear; grade 1—some fibers damaged; no laxity; grade 2— high-grade partial tear

Treatment of ACL injury: grades 1 and 2—rest; compression; ice; immobilization should be brief to prevent weakness and tightness; surgery after 6 wk; progressive weight bearing; consider preoperative physical therapy; functional brace helps provide stability; grade 3—reconstruction increases likelihood of athlete returning to competition; data suggest concomitant meniscal tear substantially increases long-term risk for arthritis (counsel patients vigorously about reconstruction)

Patellofemoral pain: most common cause of knee pain in young active women; pain over front part of knee typically worsens with activities that involve bending of knee (eg, going up and down stairs, squats); typically not swollen; assess standing or walking and foot pronation; Q angle assessment—approximate angle between line from tibial tuberosity to patella and line from anterior superior iliac spine (ASIS; palpable bump on hip) to patella; examination—check for tenderness on front of kneecap; monitor patellar tracking (watch kneecap during flexion and extension; some patients have J curve [slight twisting]); observe patellar glide (divide kneecap into 4 quadrants; patella should move 50% inward, 50% outward); check patellar tilt (grab under relaxed patella and rotate up and down to check for excessive tilt); distal patellar push test (determine whether applying downward pressure on upper knee causes aggravation or pain when patient contracts quadriceps); watch for apprehension sign (eg, “they’re grabbing your arm”) when manipulating kneecap; assess weakness of vastus medialis obliquus (VMO); x-rays—may show bipartite or tripartite patella (due to, eg, past injury, secondary ossification center that failed to join); lateral view may show patella baja (low-hanging patella) or patellar alta (high-riding patella; consider quadriceps dysfunction); Merchant’s or sunrise view of knee at 35º of flexion may show lateral tilt

Treatment of patellofemoral pain: address underlying issues (eg, biomechanical problems); ice; rest; avoid NSAIDs; avoid activities that cause irritation (eg, squatting, kneeling, bending); custom orthotics (expensive; uncomfortable); semirigid orthotics ($40) available in sporting goods stores and work well for most patients; teach patients McConnell taping technique; VMO strengthening—wall slides (stand with back against wall; bend knees and slide back down wall); leg lifts (lie flat and raise leg ≈6 in); closed-chain exercises (exercises with foot in contact with surface; eg, leg press); patellofemoral bracing offers subjective improvement; most patients respond well to conservative treatment; recovery slow (6-12 mo); surgery—lateral release procedure (loosening of outside structure of knee) may worsen pain

Stress fracture: increased risk in women and in participants of sports that require weight changes, awkward body positions, or that have significant impact on lower extremities; usually due to training error; consider intrinsic factors (mechanics, eg, inadequate muscle strength) and extrinsic factors (eg, old running shoes or running on hard, sloped roads); history and presentation—patients tend to have repeated injuries; ask about past stress injuries; routine testing for BMD not necessary; as pain and strain of abnormal force or load on bone increases, stress reaction becomes stress fracture; tibia most common site; symptoms can be variable, vague, or nonspecific; patients may be asymptomatic for weeks or months; pain usually activity-dependent; physical examination—look for bony tenderness; can be diagnosed by placing large tuning fork over bone (tuning fork should move up and down evenly, and not stop in one area); percussive tenderness or one spot more sensitive than another; assess pain while patient hops on affected foot; perform fulcrum test to identify femoral neck stress fracture (place arm under patient’s leg and push down on knee, using arm as fulcrum to lever upper femur; assess pain; important to identify); x-rays—often normal; may show, eg, thickening around periosteum, intracortical lucency or line); bone scanning—sensitive; not highly specific; does not visualize fractures; cannot be used to follow healing; MRI— imaging study of choice; sensitive and specific; helps distinguish fracture from other possible problems; treatment—rest; symptom-limited activities; when concerned about injuries in areas that tend to heal less well (eg, fifth metatarsal), consider treating early with surgery; look at biomechanics; address problems with training, pes planus, body weight, and hormonal issues; consider patient’s nutritional intake