Recurrent Stress Fracture — Free SCA Practice Case
Young woman with a recurrent stress fracture
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Materials for Candidate
Please review before starting the consultation
Full Name
Freya Watson
Age
21 years
Consultation Type
VideoAge
21
Situation
Video Consultation. Referred back by orthopaedics after a third fracture in a year.
Reason for Encounter
"My orthopaedic surgeon said I should see my GP about why I keep breaking bones. This is my third fracture this year and I want to know what's going on and how to stop it."
Medical Records
- ●PMH: Right elbow fracture (8 months ago). Left humeral fracture (6 months ago). Right wrist fracture (recent — treated with surgery; recovered well). BMI recorded 2 months ago: low (underweight range).
- ●Medications: None.
- ●Allergies: NKDA.
- ●Orthopaedics letter: 21-year-old gymnast/athlete; recovered well after fixation of a wrist fracture; given multiple fractures in the last year, recommends GP review for a possible underlying cause; discharged from orthopaedics.
Patient Script
For the friend playing the patient role
Character Overview: You are Freya, a 21-year-old competitive gymnast training hard with hopes of qualifying for the Olympics. You have had three fractures in the past year and your surgeon asked your GP to look into why. You are focused and driven. You believe you eat and drink well; you follow a high-protein diet and deliberately limit carbohydrates because you think it helps your gymnastics physique and performance — but you are not preoccupied with being "fat" and you have never made yourself sick or used laxatives. Your periods stopped 6–7 months ago and you are not sure why (you are not sexually active and a recent pregnancy test was negative). You train several hours a day. You are worried the fractures will stop you competing. If the doctor is respectful and not judgemental, you engage well; if you feel judged about your eating or training, you become defensive.
Opening Sentence: "Hi Doctor. My orthopaedic surgeon said I should come and see you because I've broken three bones in the past year and he thinks there might be an underlying reason. I'm a gymnast — I train really hard — and I'm worried this is going to stop me competing. I want to know what's causing it and how to prevent more fractures."
History if Asked (Data Gathering Phase)
- ●The fractures: "Three in the past year — my elbow, then my upper arm, now my wrist. None of them were big impacts really — the wrist was a fairly minor fall in training. That's what's worrying me."
- ●Training: "I train several hours a day. I'm aiming for the Olympics, so I push myself hard."
- ●Eating (volunteered as 'healthy'; details only if asked sensitively): "I think I eat well. I have a lot of protein and I deliberately keep my carbs low — I believe it helps my physique and performance for gymnastics."
- ●Periods (only if asked): "My periods stopped about six or seven months ago. I don't know why. I'm not pregnant — I did a test recently and I haven't been sexually active in over a year."
- ●Her view: "I'm starting to wonder if I've got weak bones or something underlying."
ICE — Ideas, Concerns, Expectations
The patient does not volunteer this information unprompted. These responses surface only when the candidate explores gently.
- ●Ideas: Freya suspects she may have weak bones or some underlying condition, but has not connected her fractures, her eating/training, and her absent periods. "I think maybe my bones are weak. I hadn't linked it to my eating or my periods stopping."
- ●Concerns: Her dominant concern is whether the fractures will affect her ability to train and compete at a high level. "My biggest worry is whether this will stop me competing — gymnastics is everything to me."
- ●Expectations: She wants the cause investigated and advice on preventing further fractures. "I want to find out what's causing it and how to stop it happening again."
If Asked — Screening, Menstrual, and Cause Assessment (approached sensitively)
The patient answers these only when directly and sensitively asked.
- ●If asked about the fracture mechanisms (low- vs high-trauma): "They were all fairly low-impact, really — not the big falls you'd expect to break a bone."
- ●If asked, sensitively, about her relationship with food and any dietary restriction: "I restrict carbohydrates on purpose, for performance and physique. I don't think I've got an eating problem — I'm just disciplined about my sport."
- ●If asked, sensitively using a screening approach, about disordered eating (e.g. the SCOFF questions): "No — I don't make myself sick, I've never used laxatives, and I don't see myself as fat or feel out of control with eating. It's about performance, not how I look." (Denies classic eating-disorder cognitions and purging; the issue is inadequate energy intake relative to training.)
- ●If asked about her menstrual history: "Periods started normally as a teenager, were regular, then stopped six or seven months ago. Not pregnant."
- ●If asked about fatigue, recurrent illness/injury, or dip in performance: "I have been more tired and a bit run-down, and my performance has plateaued, now you mention it."
- ●If asked about thyroid symptoms, galactorrhoea, or other endocrine features: "No, nothing like that."
- ●If asked about steroid use or supplements: "No steroids. I take a protein supplement, that's all."
- ●If asked about family history of osteoporosis/bone disease: "Not that I know of."
- ●If asked about mood: "My mood's okay — focused on my sport, maybe a bit stressed about competing."
Responses to Management (The Negotiation Phase)
- ●If the Doctor sensitively explains RED-S — that her body isn't getting enough energy: "So my body isn't getting enough fuel for how much I train, and that's weakened my bones and stopped my periods? I hadn't thought of it like that." (The tested point is recognising and explaining RED-S — low energy availability — sensitively and without judgement.)
- ●If the Doctor recommends investigations (bloods, DXA): "So blood tests and a bone scan? What are they looking for?" (The tested point is appropriate investigation — excluding other causes and assessing bone density.)
- ●If the Doctor recommends multidisciplinary/specialist referral: "You want me to see a sports doctor and a dietitian? Would they help me keep competing safely?" (The tested point is MDT referral — sports medicine, dietetics, and eating-disorder input if needed.)
- ●If the Doctor sensitively raises adjusting energy intake and training: "Would I have to change how I eat and train? I don't want to lose my edge for the Olympics." (The tested point is negotiating, sensitively, that restoring energy availability protects both her health and her career — deferring specifics to the specialist team.)
- ●If the Doctor addresses her goal: "Can I still aim for the Olympics if I sort this out?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Relative Energy Deficiency in Sport (RED-S)
- ●RED-S results from low energy availability — energy intake insufficient to meet the demands of training and normal physiological function. It impairs multiple systems, including bone health, menstrual/reproductive function, immunity, and performance. It is the broader successor to the "female athlete triad" (low energy availability ± disordered eating, menstrual dysfunction, low bone mineral density).
Recurrent Low-Trauma Fractures Are a Red Flag
- ●Recurrent, low-trauma fractures in a young athlete should prompt consideration of impaired bone health and RED-S — not be dismissed as unrelated sporting injuries.
Low Energy Availability Without a Classic Eating Disorder
- ●Low energy availability can arise from inadequate intake relative to a very high training load — sometimes without classic eating-disorder cognitions or purging (as here, intentional carbohydrate restriction for performance). Nonetheless, always screen sensitively for disordered eating (e.g. SCOFF), as it commonly coexists.
Menstrual Dysfunction
- ●Secondary amenorrhoea (functional hypothalamic) is a key feature. Exclude other causes (pregnancy, thyroid disease, hyperprolactinaemia, PCOS) before attributing it to RED-S.
Bone Health Assessment
- ●Assess bone health — arrange a DXA scan and ensure vitamin D and calcium adequacy. Low bone mineral density underlies the fractures.
Management Is Multidisciplinary — and Energy/Training Plans Are Specialist-Led
- ●Management centres on restoring energy availability (increasing intake relative to training and/or modifying training) and requires a multidisciplinary team — sports and exercise medicine, dietetics, and eating-disorder/psychological input as needed. The GP's role is recognition, initial investigation, and sensitive referral; specific diet, weight, and training plans are led by the specialist team, not prescribed as numeric targets in primary care.
Athlete-Aware, Non-Judgemental Care
- ●Engage the athlete's goals and frame intervention as protecting both health and performance. A judgemental or numbers-focused approach risks disengagement and can reinforce harmful behaviours.
Common Candidate Mistakes in This Case
- ●Missing RED-S: treating the fractures, amenorrhoea, and eating as unconnected, or investigating "weak bones" in isolation.
- ●Insensitive or absent eating screening: shaming her, assuming an eating disorder she denies, or failing to screen at all.
- ●Giving diet/weight/training numbers or plans: inappropriate and potentially harmful — these are specialist-led.
- ●Not referring to the MDT: trying to manage a complex condition alone, or omitting dietetic/sports-medicine input.
- ●Threatening her goals rather than protecting them: framing the advice as simply stopping her competing, so she disengages.