LAUSR

Background Lower cervical or upper thoracic spinous process avulsion fractures are commonly known as a “clay shoveler's fracture” named for the frequent injury seen in early 20th century Australian road construction workers (1). This fracture pattern has not been reported as a runner injury. A thorough literature review yielded only a few case reports of clay shoveler's fracture occurring in nontraumatic settings. Osteoporosis secondary to the female athlete triad may have been a critical predisposing risk factor for this rare fracture. The female athlete triad is defined as a medical condition often observed in physically active girls andwomen and involves three components: 1) low-energy availability with or without disordered eating, 2) menstrual dysfunction, and 3) low bone mineral density. Female athletes often present with one or more of the three triad components, and early intervention is essential to prevent its progression to serious end points that include clinical eating disorders, amenorrhea, and osteoporosis (2). The female athlete triad has been further elaborated with the more recent concept of Relative Energy Deficiency in Sport (RED-S). RED-S refers to impaired physiological functioning caused by relative energy deficiency and includes, but is not limited to, impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health (3). Low-energy availability (LEA), the etiologic requirement of RED-S, is a mismatch between an athlete's energy intake (diet) and the energy expended in exercise, leaving inadequate energy to support the functions required by the body to maintain optimal health and performance, leading to numerous adverse physiologic consequences. There are known impairments of metabolic rate, menstrual function, bone health, immunity, protein synthesis, and cardiovascular health (3). Research regarding these syndromes has helped increase understanding of not only how and why these