age is really just a number

A story of one runner’s battle with stress fractures

“Dr. Crane, I just don’t understand why I keep breaking myself. I’m not trying to do anything crazy. I’m just trying to run around 15 miles a week. I’m not even going that fast.” Alice lamented. “I’ve changed my shoes, increased my milage slowly, and I try to run on soft surfaces – but I keep getting stress fractures. What’s going on?” Alice asked with a heavy sigh.

“Alice, I’m not really sure why you keep getting stress fractures. Is this the third one in your right foot this year?” I asked. “Let’s get a bone density exam and see if this is the underlying issue. Your shoes are good for your foot type, your orthotics are almost brand new, and your gait looks really good at this point. It sounds like your training plan is solid. I think there must be something else going on. Any family history of osteopenia or osteoporosis?” I inquired.

“My mother has osteoporosis, but she’s 80! I’m only 50!” Alice exclaimed. “She didn’t start having any issues until her 70’s when she fell and broke her hip. It still hurts her. Do you really think my bones are that brittle?”

“It’s definitely possible,” I replied empathetically. “You are the poster child for osteoporosis. You are white, thin, small in stature and had a hysterectomy a few years ago. All of these are risk factors for osteoporosis that you can’t change. I know you don’t smoke, but do you take a lot of antacids like Prilosec? Long term usage of protein pump inhibitors can also increase your risk. Even a bad Diet Coke habit can increase your risk. Crazy, but true! Let’s just get a bone density test and see where you are at. If it’s not osteopenia, then we really need to look at your training log to see if I can figure out a training error that could be contributing to all these stress fractures. If it is osteopenia or osteoporosis, then I will refer you to my favorite endocrinologist so they can discuss new medical treatments. Don’t despair, we can tackle this issue together as a team!”

Alice returned a week later with her bone density test results. Her T-score was -1.89, which for a 50-year-old woman is osteopenia and almost in the realm of osteoporosis. Let me explain how we got this diagnosis.

Dual-energy X-ray absorptiometry (DEXA scan) is a means of measuring bone mineral density (BMD) using spectral imaging. Two X-ray beams with different energy levels are aimed at the patient’s bones. When you subtract out soft tissue absorption, you can determine the bone mineral density (BMD) from the absorption of each beam by bone. The DEXA scan is the most widely used bone density measurement technology and is considered the gold standard for diagnosing osteoporosis. The diagnosis of osteoporosis is when the bone mineral density is less than or equal to 2.5 standard deviations below that of a young (30–40-year-old), healthy adult women reference population. Bone density translates as a T-score. But because bone density decreases with age, more people become osteoporotic with increasing age.

The World Health Organization has established the following diagnostic guidelines:

*WHO (1994). “Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report of a WHO Study Group”. World Health Organization Technical Report Series. 843: 1–129

“Well, Alice, at least we now know what we are dealing with,” I explained gently.

“Osteoporosis just seems to be an old person disease. I’m not that old,” Alice exclaimed.

“It can happen for lots of different reasons,” I explained, “And now that the devil has a name, we can treat it. We measured your Vitamin D levels last week and they were low as well. Have you started your calcium and Vitamin D supplements?”

“Yes, I take the horse pill with the little Vitamin D capsule. You said to take at least 500 mg of Calcium with 1000 IU of Vitamin D? Correct?” Alice inquired.

“Yes, keep it simple. You can actually find a mixed bone supplement so you only have to take one pill. Start with at least 500 mg of Calcium and 1000 IU (25 mcg) of Vitamin D every morning. For maximum absorption, your supplement should have Calcium Hydroxyapatite paired with Vitamins D3 and K2. We will recheck your levels in 3 months and see how you are doing. Let me know if you have any stomach issues from the supplements. And when is your endocrinology appointment?” I asked as I closed her chart.

“Do I really need to go to the endocrinologist?” asked Alice sheepishly. “Seems like you have it under control.”

“Yes, I would recommend that you go. They specialize in osteoporosis. I’ve got your basics covered, but they can narrow down why it is affecting you at such a young age. They may not do anything else, but at least you have two pairs of eyes looking at your problem. Better safe, then sorry.” I answered.

“OK, I will keep the appointment.”

Alice is not alone. An estimated 200 million people have osteoporosis, and it is more common with age. About 15% of Caucasians in their 50s and 70% of those over 80 are affected. It is more common in women than men. Postmenopausal women have a higher rate of osteoporosis and fractures than older men. Postmenopausal women have decreased estrogen, which contributes to their higher rates of osteoporosis. A 60-year-old woman has a 44% fracture risk, while a 60-year-old man has a 25% fracture risk.

There are 8.9 million fractures worldwide per year due to osteoporosis. Globally, 1 in 3 women and 1 in 5 men over 50 will have an osteoporotic fracture. We are winning the fight with increased awareness and supplementation. Data from the United States shows a decrease in osteoporosis in white women, from 18% in 1994 to 10% in 2014. White and Asian people are at greater risk. People of African descent are at a decreased risk of fractures due to osteoporosis, although they have the highest risk of death following an osteoporotic fracture.

If Alice’s story sounds familiar, you should talk with your doctor and get a bone density test. They can rule out any other causes like poor biomechanics, improper shoe gear, or training errors. Osteopenia or osteoporosis can cause chronic stress fractures, and an occult fracture (one with no known identifiable cause) is usually one of the first signs of bone loss. The sooner you start treating your frail bones, the better the long-term outcome.

Osteoporosis can lead to significant disability as you age, so you should take it seriously. Talk with your doctor about your concerns. Retrospective studies show that almost 50% of those that break a hip later in life never fully recover, 10% end up in a long-term care facility, and a shocking 33% die within a year. Scary statistics!