“That’s my third stress fracture this year — just sort my foot so I can keep training”

A single stress fracture can be a training error, but THREE in a year in a young female runner is a red flag for a systemic cause — RELATIVE ENERGY DEFICIENCY IN SPORT (RED-S) — not just a foot to fix, so resist the patient’s "just sort it" framing. RED-S arises from low energy availability (insufficient intake for training expenditure, intentional or not) and — while the IOC 2023 consensus (international) describes REDs as wider than the older female athlete triad, affecting men too — the triad’s core is low energy availability (with or without disordered eating), menstrual dysfunction (amenorrhoea/oligomenorrhoea from hypothalamic suppression), and impaired bone health (low density causing stress fractures), alongside effects on mood, immunity and performance. Screen eating and energy availability sensitively and non-judgementally (intake versus training volume, restriction, weight/body preoccupation, purging, beliefs about thinness and performance — a tool such as SCOFF only as a prompt, never the sole basis, NICE NG69), recognising disordered eating in athletes is common and often hidden behind "clean eating" or performance goals. Take a menstrual history — amenorrhoea/oligomenorrhoea is a cardinal sign and major bone-health risk, the combined pill can MASK it by producing withdrawal bleeds, and lost periods in an athlete are never "just from running". Examine face to face (not possible on video; physical risk assessment if eating is restricted, RCPsych MEED CR233) and investigate appropriately (confirm the fracture; FBC, ferritin, vitamin D, TFTs, coeliac; in amenorrhoea a pregnancy test first, then LH, FSH, oestradiol and prolactin; consider DEXA for bone density, NICE NG69) and manage the energy deficiency, not just the bone, with multidisciplinary referral (sports medicine, dietitian, eating-disorder services/psychology), optimised vitamin D/calcium, the knowledge that the combined pill does not protect bone, and modified training with adequate fuelling — the bone will not heal durably without correcting the energy deficit. The hidden agenda is that training/performance and possibly eating/body control are central to her identity, with minimisation, perfectionism or an eating disorder beneath and fear of losing running; engage gently, connect the fractures to under-fuelling, frame fuelling as the route to performance, and bring her toward help without shaming.