Working Diagnosis:
The patient was diagnosed with recurrent BSI in the setting of Celiac Disease.

Treatment:
The patient underwent symptomatic offloading for 6 weeks and subsequently completed a graded return-to-run program under the guidance of an athletic trainer. The vitamin D deficiency was appropriately treated with supplementation.

Although he was asymptomatic from a gastrointestinal standpoint, he was advised to follow a lifelong gluten-free diet following the diagnosis of celiac disease.

Outcome:
The patient was diagnosed with recurrent BSI and celiac disease. He completed a graded return-to-run program and has not experienced recurrent symptoms since diagnosis.

Author's Comments:
This case highlights the potential association between celiac disease and recurrent BSI in an otherwise asymptomatic athlete.

Although celiac disease is not currently a routinely recommended screening condition in asymptomatic patients with BSI, studies have demonstrated an increased prevalence of celiac disease among individuals with BSI compared with the general population. Celiac disease has also been associated with vitamin D deficiency, an independent risk factor for BSI. Current recommendations for patients with a history of BSI include evaluation for vitamin D deficiency, calcium deficiency, and disordered eating. However, universal laboratory screening for celiac disease in individuals with recurrent bone stress injuries who lack gastrointestinal symptoms has not been established as the standard of care.

This case demonstrates how recurrent BSI may be an initial manifestation of previously undiagnosed celiac disease. Given the relatively low cost of Anti-tTG IgA testing, approximately $80 as a send out lab, additional research is warranted to determine whether targeted screening of patients with recurrent BSI would improve the detection and treatment of celiac disease and lead to meaningful clinical outcomes.

Editor's Comments:
This case highlights the importance of maintaining a broad differential diagnosis when evaluating athletes with recurrent BSI, particularly when traditional risk factors do not fully explain the clinical presentation. A key teaching point is that recurrent BSI should prompt consideration of underlying systemic contributors to impaired bone health, including nutritional deficiencies, relative energy deficiency, endocrine abnormalities, and gastrointestinal disorders.

The educational value of this case stems from the identification of previously unrecognized celiac disease in an otherwise asymptomatic endurance athlete. The case demonstrates how a comprehensive metabolic evaluation, initiated because of recurrent BSI, led to the diagnosis of celiac disease and severe vitamin D deficiency, both of which are associated with reduced bone mineralization and increased susceptibility to stress injury. It further emphasizes that the absence of gastrointestinal symptoms does not exclude celiac disease and illustrates the potential role of targeted laboratory screening in selected high-risk athletes.

This case also provides an opportunity to discuss current gaps in screening recommendations, as celiac disease is not routinely evaluated in asymptomatic patients with recurrent bone stress injuries despite emerging evidence suggesting a higher prevalence in this population. The case reinforces the importance of investigating secondary causes of bone stress injury and encourages clinicians to consider multidisciplinary evaluation when recurrent injuries occur.

References:
1. Smith, Ralph et al. "Incidence of Undiagnosed Celiac Disease Presenting as Bone Stress Injuries to a Sport and Exercise Medicine Clinic." Clinical journal of sport medicine : official journal of the Canadian Academy of Sport Medicine vol. 31,6 (2021): e306-e312. doi:10.1097/JSM.0000000000000820

2. Joy, Elizabeth et al. "2014 female athlete triad coalition consensus statement on treatment and return to play of the female athlete triad." Current sports medicine reports vol. 13,4 (2014): 219-32. doi:10.1249/JSR.0000000000000077

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