Counsel a parent and a young athlete on low energy availability and the return-to-running plan — OSCE

Communication framework

Establish what the mother already understands and fears. Ask her to tell you, in her own words, what has happened so far and what she is most worried about. The fear of losing the team place, the anxiety about a permanent bone or fertility problem, and the confusion about why her daughter must stop running and eat more when her weight seems healthy are the three concerns you will spend the most time addressing, and you address them with plain language and with the explanation of why resting and re-fuelling now gives her daughter the best chance of a full return. Do not launch into the plan before you have heard her. [9]

Explain the diagnosis in plain language, without jargon. Tell her that her daughter has been training harder than her body can fuel, and that the energy gap has caused two things — a small crack in the bone of her shin from the unaccustomed load, and the pause in her menstrual cycle because the body, short of energy, has switched off the reproductive system to protect the essential functions. Use the image of a bank account where the training is spending more than the food is depositing, so the body goes into deficit. Avoid the terms energy availability and functional hypothalamic amenorrhoea unless you translate them, and check her understanding by asking her to repeat back the key idea. The good news is that both the bone and the cycle recover when the energy balance is restored. [5] [9]

Address the training reduction and the increased food directly and honestly. The reason the running must stop now is that every step loads the cracked bone and prevents the healing, and a bone that keeps being loaded may progress to a complete break that takes far longer to heal or that needs surgery. The reason the food must increase is that the energy restoration is the actual treatment — it is what switches the reproductive system back on and what rebuilds the bone — and there is no pill or supplement that can do what the food does. Frame the temporary pause and the increased intake as the investment in a full return, not as a punishment, and acknowledge how hard this is for a competitive runner. The combined oral contraceptive pill, if it comes up, does not rebuild the bone and it masks the cycle, so it is not the first step. [6] [5]

Outline the plan and the timeline. The plan has four parts. First, the protected rest of the shin to let the crack heal, with the pain-free gentle activity like the swimming or the cycling to maintain the fitness. Second, the increased food intake worked out with the dietitian, with the extra energy spread across the day and timed around the training, and the weight gently restored. Third, the work with the psychologist or the counsellor if the changes to her body or her training are causing distress, because the mind is as much a part of the recovery as the bone. Fourth, the graded return to running once the bone is healed, the energy balance is restored, and the menstrual cycle is returning, guided by the symptoms and the team. An operation is not needed for the tibial stress fracture, and the fertility is not permanently affected by the temporary pause in the cycle. [9] [6]

Invite questions and confirm the shared decision. Ask whether she has any questions, address the specific fears she raised at the start, and confirm the plan. Document the discussion, and ensure she has a named team member, a dietitian contact, and a follow-up appointment. The mother who feels heard, informed, and supported is the mother who helps her daughter through the weeks of rest and re-fuelling that follow, and the communication is as much a part of the management as the energy restoration. [6] [9]