Working Diagnosis:
Uncontrolled type 1 diabetes mellitus with elevated blood cholesterol and vitamin D deficiency resulting in repetitive fracture of the fifth metatarsal from overuse.

Treatment:
She was hospitalized for two days to control her blood sugar in order to prevent development of diabetic ketoacidosis. She was discharged on insulin glargine and lispro and provided education on carbohydrate counting. Supplementation of vitamin D was initiated, and she continued her care with orthopedics for managing her fifth metatarsal fracture.

Outcome:
Recommendations were made to meet with a sports dietician. Dietary education was re-emphasized along with carbohydrate counting. Blood sugars improved as well as cholesterol. Vitamin D level was 47 ng/mL after supplementation. She returned to a healthy, active lifestyle, including sports, with adequate rest periods.

Author's Comments:
Type I diabetes mellitus develops due to an immune-associated destruction of insulin-producing pancreatic beta cells. Polydipsia, polyphagia, and polyuria along with overt hyperglycemia remain diagnostic hallmarks in children and adolescents. Vitamin D deficiency is prevalent worldwide and causes osteopenia, precipitates and exacerbates osteoporosis, causes rickets, and increases muscle weakness, which worsens the risk of falls and fractures. The musculoskeletal system, if subjected to excessive stress, can suffer from various types of overuse injuries which may especially affect the bone in pediatric athletes with open growth plates.

Editor's Comments:
It is not uncommon for active and fit athletes with relative energy deficiency syndrome to have a normal BMI due to a muscular physique. Clinicians should have a low index of suspicion for these disorders when evaluating a patient with multiple fractures regardless of BMI.

References:
Atkinson MA, Eisenbarth GS, Michels AW. Type 1 diabetes. Lancet. 2014;383(9911):69-82. doi:10.1016/S0140-6736(13)60591-7.

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