An 18-year-old woman comes to the office due to 3 days of right foot pain. She is a ballet dancer and has been practicing intensely over the last few weeks for an upcoming show. The patient is under a lot of stress and is worried that the pain may limit her practice sessions. She has no medical history other than a left tibia stress fracture a year ago. The patient has irregular menses, and her last menstrual period was 12 weeks ago. She does not use tobacco, alcohol, or illicit drugs.
BMI is 17 kg/m². There is focal tenderness over the right fourth metatarsal shaft. Urine pregnancy test is negative.
Which of the following is the most appropriate next step in management of this patient?

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11ec193a_993f_4246_853d_cb18d55c82a3_MD0002_00 This patient most likely has a metatarsal shaft stress fracture due to repetitive weight-bearing activities (eg, running, dancing). Risk factors include an abrupt increase in activity, obesity, a prior stress fracture, low bone mineral density, and ill-fitting shoes. Patients typically develop localized pain and swelling in the second, third, or fourth metatarsal. The diagnosis is made clinically but may require plain x-rays (can be negative up to 6 weeks after symptom onset). Treatment includes activity modification/restriction and analgesics for 4-6 weeks, risk factor reduction, and gradual resumption of activity when pain free. This avid dancer's presentation of low BMI, irregular menses, and recurrent stress fractures is concerning for the female athlete triad: Low available energy (eg, low caloric intake, high exercise output), menstrual dysfunction (eg, amenorrhea, oligomenorrhea), and decreased bone mineral density. Stress fractures are more common in adolescent athletes with abnormal eating patterns due to a combination of estrogen and nutrient deficiencies. Therefore, these patients require screening for an eating disorder. (Choice A) Orthopedic referral is reserved for stress fractures at sites (eg, proximal fifth metatarsal) with high risk for nonunion, long-term disability, or delayed healing. (Choice B) Imaging modalities such as CT scan, MRI, and ultrasound are used in the evaluation of atypical (eg, extensive, intra-articular) stress fractures or as part of a presurgical evaluation. (Choice C) Physical therapy is not typically recommended for metatarsal stress fractures. Instead, non-weight-bearing activity (eg, swimming) and analgesics are suggested for 4-6 weeks. (Choice E) Lifestyle modifications (eg, reduced exercise, increased caloric intake) are the mainstay of treatment for the female athlete triad. Combined estrogen/progestin contraception can be used for patients who fail lifestyle changes. Bisphosphonates are reserved for those who fail both lifestyle changes and estrogen therapy. Educational objective: Metatarsal shaft stress fracture is due to repetitive weight-bearing activities, especially following an abrupt increase in activity. Patients with the female athlete triad (decreased energy availability, menstrual dysfunction, decreased bone density) are at risk for stress fractures and require screening for an underlying eating disorder. __________ References: Overuse injuries in professional ballet: influence of age and years of professional practice. (http://www.ncbi.nlm.nih.gov/pubmed/28695138) Metatarsal stress fractures. (http://www.ncbi.nlm.nih.gov/pubmed/28759508) 2016 update on eating disorders in athletes: a comprehensive narrative review with a focus on clinical assessment and management. (http://www.ncbi.nlm.nih.gov/pubmed/26782763)

An 18-Year-Old Woman Comes to the Office Due to 3