cising women experience amenorrhea; in elite athletes and professional ballet dancers, the prevalence may be as high as 50 percent. Amenorrhea or oligomenorrhea (a decreased number of yearly menstrual cycles) leads to a low estrogen state which decreases the bone mineral density , further increasing the risk of stress fractures. Estrogen supplementation in the form of oral contraceptives may provide a protective effect by maintaining the bone mineral density in these athletes.


DIAGNOSIS
Obtaining a proper diagnosis al ways starts with a thorough history . Most athletes describe an insidious onset of pain over a two- to three-week course that may correlate with a recent change in training. There usually is no history of trauma. Runners report an increase in their mileage or intensity prior to the onset of pain. Military recruits often develop stress fractures in their feet during the onset of boot camp. Symptoms are. usually aggravated by exercise and relieved with rest. Initially, pain occurs during weight bearing only; however, as the stress fracture progresses, pain begins earlier during the sport activity and lasts for a longer duration after rest. In addition to palpation, other activities such as walking or jogging in the office hallway may reproduce the patient's symptoms.

On physical examination, these patients usually have point tenderness over the location of the stress fracture. In the femur, the localization of stress fractures may be more difficult due to the overlying large soft tissue envelope. The fulcrum test may aid in early