Station 39

Emily Johnson

Age: 21 years old female

Full Case

Station List
Doctor
Patient
Examiner

Patient’s Data​

Patient’s name: Emily Johnson

Age: 21-year-old female 

Past medical history

  • Right elbow fracture – 8 months ago (treated conservatively)
  • Left humeral fracture – 6 months ago (treated conservatively)
  • BMI recorded 2 months ago: 16.5 (underweight)

Drug and Allergy History

  • Nil

Recent Notes/ Consultation

Letter from Orthopaedics

Dear GP,

Emily Johnson, a 21-year-old gymnast and athlete, was admitted following a fall that resulted in a right wrist fracture. She underwent open reduction and internal fixation (ORIF) of the right wrist.

Emily is now 6 weeks post-ORIF and has made a good recovery. The surgical wound is well-healed, and radiographic imaging shows satisfactory alignment and healing of the fracture. She has regained near-full range of motion in her right wrist and is pain-free.

She has completed her postoperative physiotherapy regimen and no longer requires specialist follow-up in the orthopaedic clinic.

Given her history of multiple fractures in the last year, I recommend a review with her GP to discuss the possibility of an underlying condition contributing to these recurrent fractures. I have now discharged her back to your able hands

Regards, 

Mr Philip Onwudiwe, FRCS(Ortho), MCh (Sheffield)

Consultant Trauma and Orthopaedic surgeon  

Patient has booked a telephone consultation to discuss the letter from orthopaedics and her recent history of multiple fractures.

Patient's Story (Role player’s brief)

Patient’s Story 

You are Emily Johnson, a 21-year-old gymnast, calling today because your orthopaedic surgeon advised a follow-up with your GP to explore possible reasons for your recurrent fractures. 

Six weeks ago, you sustained a right wrist fracture following a minor fall during gymnastics training. You had surgery (ORIF) and have since recovered well, with good wrist function and no ongoing pain.

However, you are becoming increasingly concerned, as this is now your third fracture in the past year—you previously fractured your right elbow (8 months ago) and left shoulder (6 months ago).

Only disclose the following if specifically asked:

You have not had a menstrual period for the past 6–7 months, and you’re unsure why. You are not pregnant; you took a pregnancy test two days ago which came back negative as expected as you haven’t been sexually active in over a year.

You believe you eat and drink well. You are not preoccupied with your weight or concerned about being fat.

Your diet is primarily high in protein, and you intentionally avoid carbohydrates to maintain a physique suitable for gymnastics. You are aware that you are slim, but you are not obsessed with your weight. You have never used laxatives or made yourself sick after eating.

You exercise 3–4 hours daily as part of your fitness routine, aiming to qualify for the Olympics. 

Social History: You do not smoke and do not drink alcohol. You currently live with your parents. You work part time in a book shop 

Idea: You’re beginning to suspect that you may have weak bones or an underlying condition.

Concern: You’re worried about whether these fractures will affect your ability to return to high-level gymnastics and potentially compete professionally.

Expectation: You would like the GP to investigate what’s causing these fractures and advise you on how to prevent further injury.

Question for the Doctor:

“How can I prevent future fractures?”

Say NO to any other questions asked outside of the details already provided in the scenario. Accept anything offered to you by the doctor.    

Marking Scheme

Data Gathering and Diagnosis 

  • Ask about the nature of the fall that caused the wrist fracture—clarify whether it was a high-impact injury or a minor fall.
  • Ask if the patient has experienced any other recent falls or similar incidents.
  • Ask about hand dominance, confirm if the patient is right-handed, and explore how she is coping functionally since the injury involved her dominant hand.
  • Ask when the previous fractures occurred and whether they were caused by significant trauma or minor accidents.
  • Ask about her daily diet, including whether she consumes adequate calcium and vitamin D, and if she follows any dietary restrictions.
  • Ask about concerns around weight and dietary behaviours, including whether she is restricting food for appearance or performance reasons, and screen for disordered eating using key questions such as: “Do you ever make yourself sick because you feel uncomfortably full?”, “Do you worry that you have lost control over how much you eat?”, “Have you recently lost more than one stone in a 3-month period?”, “Do you believe yourself to be fat when others say you are too thin?”, and “Would you say that food dominates your life?” 
  • Ask about her menstrual cycle, including whether her periods are regular, if she has had any recent changes or missed periods, and whether there is any possibility of pregnancy.
  • Ask about her training routine, including how many hours per day she exercises and the intensity of her training.
  • Ask if she has been advised by any professionals to modify or reduce her activity levels following her fractures.
  • Ask about the use of any over-the-counter medications, particularly steroids or supplements.
  • Ask about any family history of osteoporosis or other bone-related conditions.
  • Ask about other health concerns, including unexplained weight loss, fatigue, or any other systemic symptoms.
  • Make a working diagnosis of Relative Energy Deficiency in Sport (RED-S)

Example of explanation to patient​

Emily, based on your history of frequent fractures, your low weight, the intensity of your exercise routine, and the fact that your periods have stopped, it seems your body is not getting enough energy and nutrients to meet its needs. This has likely led to weakened bones, frequent fractures and no periods

Putting all these factors together, there’s a condition called Relative Energy Deficiency in Sport, or RED-S for short. You may have heard of its older name, the female athlete triad, but RED-S is a broader term. It explains how insufficient nutrition, despite heavy physical activity, can negatively affect your bones, hormones, and overall health.

Now, I want to emphasise that exercise is absolutely good for you, especially as an athlete, but when it’s combined with a restrictive diet, it can start to harm the body instead of helping it. What your body needs right now is more fuel, in the form of balanced nutrition and rest, to support your training, bone health, and hormone function.

The good news is that with the right support, we can work together to help you restore your energy levels, get your periods back, and reduce the risk of future fractures, all while helping you stay fit and active in the sport you love.

Does all of that make sense?

Management

Management 

  • Arrange blood tests to investigate underlying causes: Full Blood Count (FBC), Urea and Electrolytes (U&Es), Liver Function Tests (LFTs), Thyroid Function Tests, HbA1c, Calcium and Bone Profile, Vitamin D level, and a full hormone profile (including FSH, LH, Oestradiol, and Prolactin).
  • Refer for a DEXA scan immediately (without calculating a FRAX score) due to her BMI being below 18.5 and a history of multiple fractures, which already places her at high risk for osteoporosis.
  • Advise that depending on DEXA results, if there is evidence of low bone density or osteoporosis, liaison with a rheumatologist may be necessary for further specialist input.
  • If hormone levels are abnormal, refer to endocrinology for assessment. Inform the patient that hormone replacement therapy may be considered by endocrinologist depending on findings.
  • Assess for calcium and vitamin D deficiency by asking about dietary intake and sun exposure and use a calcium calculator to estimate her intake. 
  • Advise that she will be started on supplementation if calcium or vitamin D levels are found to be low.  
  • Advise that you will refer her to a dietitian to help optimise her nutrition and ensure she is meeting her body’s energy and nutrient needs to support bone health and overall wellbeing.
  • Advise on modifying exercise levels by recommending a reduction in high-intensity training to support healthy weight restoration and reduce fracture risk and suggest involving a sports physiotherapist to create a safe and balanced plan that supports her athletic goals without compromising bone health. 
  • Discuss other bone-strengthening strategies by encouraging weight-bearing and resistance exercises, as tolerated, to help build bone and muscle strength.
  • Safety net: Advise Emily to recontact the surgery if she experiences another fracture, significant pain, or worsening symptoms.
  • Arrange follow-up appointment to review blood test and DEXA scan results, discuss the diagnosis in more detail, and plan further management.

Learning point from this station: ​

Relative Energy Deficiency in Sport (RED-S) is a serious condition caused by low energy availability—when the body’s energy intake is insufficient to support both the demands of exercise and essential physiological functions. It was formerly known as the Female Athlete Triad (low energy availability, amenorrhoea, and low bone density), but the International Olympic Committee (IOC) broadened the term in 2014 to reflect the condition’s impact across multiple body systems and its occurrence in both male and female athletes.

RED-S is particularly common in sports or disciplines that place value on low body weight or aesthetics (e.g. gymnastics, long-distance running, dance). It may occur with or without disordered eating and can overlap with clinical eating disorders like anorexia.

Key features include:

  • Amenorrhoea (in females), due to suppression of the hypothalamic-pituitary-gonadal axis.
  • Low bone density, increasing the risk of stress fractures and long-term osteoporosis.
  • Decreased performance despite training, due to impaired physiological adaptation.
  • Oestrogen plays a crucial role in bone metabolism, and its deficiency—as seen in amenorrhoea—can significantly impair calcium absorption and bone strength.

Clinical Investigations:

To evaluate RED-S and exclude other causes:

  • Females: FSH, LH, oestradiol, testosterone, pregnancy test.
  • Males: Testosterone, LH.
  • All athletes: FBC, thyroid function, vitamin D, vitamin B12, ferritin, prolactin, 9am cortisol.
  • DEXA scan is essential for those with amenorrhoea or history of multiple fractures.
  • Consider coeliac screen or faecal calprotectin if GI symptoms are present.

Management Approach:

Multidisciplinary care is crucial: dietitian (for nutritional rehabilitation), sports physiotherapist (for safe training adaptation), psychologist (if eating disorders are suspected), endocrinologist (for hormone assessment and treatment) and a rheumatologist if osteoporosis or other bone conditions require specialist attention.

Avoid using the combined oral contraceptive pill (COCP) to ‘regulate’ periods in RED-S, as it can mask true hormonal status and worsen bone health.

Hormone replacement therapy (HRT) prescribed under specialist care is preferred as a temporary measure while the underlying energy imbalance is corrected.

Early recognition and management of RED-S are essential to prevent long-term health consequences and support safe return to sport

Further reading