Stress Fractures from Wheat Gluten Sensitivity, Two Cases

by Jeffrey Dach MD

A 22 year old female came to see me for repeated stress fracture in her feet involving the metatarsal bones.  A previous doctor, a rheumatologist,  prescribed Fosamax, a bisphosphonate drug for low bone density on a DEXA scan.  Lab testing showed markedly elevated anti-gliadin antibodies indicating severe gluten sensitivity.  This patient was placed on a wheat free diet. Above image shows stress fracture of mid femur due to wheat gluten sensitivity. Courtesy of Lee,et al “Surgical Treatment of the Atypical Femoral Fracture” Hip & pelvis 2018

Second Case

A 55 year old golfer stepped in a hole at the golf course and suffered a transverse fracture of the mid femur.  After surgical repair with rod and nail, the orthopedic surgeon told him he sustained a “stress fracture” .  Lab testing showed massively elevated anti-gliadin antibody levels indicating severe gluten sensitivity.  This patient was eating wheat products daily.

Wheat Sensitivity and Malabsorption

In the most severe form of wheat gluten sensitivity called Celiac Disease, malabsorption due to inflammation in the gut lining is fairly common. The immune response to wheat gluten actually causes loss of the brush border of the small bowel, a form of enteric atrophy.  This leads to calcium malabsorption and stress fracture in these patients.   Malabsorption of other nutrients such as Iron, B12, and triglycerides may also be present and reveal the underlying gluten (wheat) sensitivity.

in 2008, Dr Olmos did a systematic review of the medical literature finding more than 400 articles reporting the association of celiac disease with metabolic bone alterations.(16)  Dr Olmos says:

“Thus, our systematic review identified a great number of papers (>400) recognizing the association between CD and bone metabolic alterations. This body of evidence strongly suggests that CD should be considered as one of the leading conditions predisposing to bone damage.”(16)

Treatment with Gluten Free Diet

Both patients were treated with Gluten-Free (wheat free) Diet, As well as calcium, magnesium, vitamin D3 and Vitamin K2 supplements with no further fractures reported. Link to this Article

Jeffrey Dach MD
7450 Griffin Road Suite 180
Davie, Fl 33314
954-792-4663

Articles with  Related Interest:

Wheat Gluten and Celiac Disease Part One

References

1) Tins, Bernhard J., et al. “Stress fracture of the pelvis and lower limbs including atypical femoral fractures—a review.” Insights into imaging 6.1 (2015): 97-110.February 2015, Volume 6, Issue 1, pp 97–110 |

2) Thakur, Amit, et al. “Femoral Neck Fatigue Fracture as the First Manifestation of Celiac Disease: A Case Report.” IJSS 2.10 (2016): 13.Femoral Neck Fatigue Fracture as First Manifestation of Celiac Disease Thakur Amit IJSS 2016

Young individuals with fatigue fractures are often a result of the repetitive athletic activity. Military recruits, distance runners, and dancers are commonly affected and are at an increased risk of developing stress fractures in the hip. We report a case of fatigue fracture of the femoral neck in a 20-year-old software professional as the first presentation of celiac disease. The skeletal manifestation of celiac disease is rare (0.6%). The case was managed with in situ fixation with cannulated screws and gluten free diet. The patient was pain free with no evidence of osteonecrosis, nonunion, or any other complication at 1-year follow-up.

3) Rubinstein, A., et al. “Bilateral femoral neck fractures as a result of coeliac disease.” Postgraduate medical journal 58.675 (1982): 61-62.Femoral Neck Fatigue Fracture as First Manifestation of Celiac Disease Thakur Amit IJSS 2016

4) Selek, Ozgur, Kaya Memisoglu, and Alev Selek. “Bilateral femoral neck fatigue fracture due to osteomalacia secondary to celiac disease: Report of three cases.” Archives of Iranian medicine 18.8 (2015): 542.Bilateral femoral neck fatigue fracture due to osteomalacia secondary to celiac disease Selek Arch Iranian med 2015

5) Rastogi, Ashu, et al. “Celiac disease: a missed cause of metabolic bone disease.” Indian journal of endocrinology and metabolism 16.5 (2012): 780.

6) Topal, Erdem, et al. “Vitamin and mineral deficiency in children newly diagnosed with celiac disease.” Turkish journal of medical sciences 45.4 (2015): 833-836.Vitamin and mineral deficiency in children newly diagnosed with celiac disease Topal Erdem Turkish j med sci 2015

Materials and methods: The files of patients diagnosed with celiac disease in our Pediatric Gastroenterology Clinic from June 2008 to
June 2013 were reviewed retrospectively.
Results: A total of 52 pediatric patients diagnosed with celiac disease via serology and duodenal biopsy and who fulfilled the study
criteria were enrolled in the study. The mean diagnosis age of the patients was 8.5 ± 3.9 years and 33 (63.5%) of the patients were female.
Vitamin D, vitamin A, vitamin E, zinc, and iron deficiencies were determined in 27 (51.9%), 4 (7.7%), 7 (13.5%), 35 (67.3%), and 18
(34.6%) patients, respectively, at the time of diagnosis. Vitamin D deficiency was observed more frequently in patients with growth
retardation at the time of application (P = 0.02).
Conclusion: Vitamin D, zinc, and iron deficiency are frequently observed in pediatric patients with celiac disease at the time of diagnosis.
Therefore, serum vitamin D, zinc, and iron levels should be checked in all children diagnosed with celiac disease.

7) Capriles, Vanessa D., Ligia A. Martini, and José Alfredo G. Arêas. “Metabolic osteopathy in celiac disease: importance of a gluten-free diet.” Nutrition reviews 67.10 (2009): 599-606.

Reduced bone mineral density (BMD) is frequently found in individuals with untreated celiac disease (CD), possibly due to calcium and vitamin D malabsorption, release of pro-inflammatory cytokines, and misbalanced bone remodeling. A gluten-free diet (GFD) promotes a rapid increase in BMD that leads to complete recovery of bone mineralization in children. Children may attain normal peak bone mass if the diagnosis is made and treatment is given before puberty, thereby preventing osteoporosis in later life. A GFD improves, but rarely normalizes, BMD in patients diagnosed with CD in adulthood. In some cases, nutritional supplementation may be necessary. More information on therapeutic alternatives is needed.

8) Krupa-Kozak, Urszula. “Pathologic bone alterations in celiac disease: etiology, epidemiology, and treatment.” Nutrition 30.1 (2014): 16-24.Pathologic bone alterations in celiac disease Krupa-Kozak Urszula Nutrition 2014

9) Xing, Yanming, and Sarah L. Morgan. “Celiac disease and metabolic bone disease.” Journal of Clinical Densitometry 16.4 (2013): 439-444.

10) Stein, Emily M., et al. “Abnormal skeletal strength and microarchitecture in women with celiac disease.” The Journal of Clinical Endocrinology & Metabolism 100.6 (2015): 2347-2353.

11) Yang, Yu-Xiao, et al. “Long-term proton pump inhibitor therapy and risk of hip fracture.” Jama 296.24 (2006): 2947-2953.’

12) Mulder, Christopher J., Anthony P. Cardile, and Judith Dickert. “Celiac disease presenting as severe osteopenia.” Hawaii medical journal 70.11 (2011): 242.

13) Tahiri, Latifa, et al. “Celiac disease causing severe osteomalacia: an association still present in Morocco!.” The Pan African medical journal 19 (2014).

16) Olmos, M., et al. “Systematic review and meta-analysis of observational studies on the prevalence of fractures in coeliac disease.” (2008): 46. Systematic review and meta-analysis of observational studies on the prevalence of fractures in coeliac disease Olmos 2008

Thus, our systematic review identified a great number of papers (>400) recognising the association between CD and bone metabolic alterations. This body of evidence strongly suggests that CD should be con- sidered as one of the leading conditions predisposing to bone damage.

Header image courtesy of:  Lee, Kyung-Jae, and Byung-Woo Min. “Surgical Treatment of the Atypical Femoral Fracture: Overcoming Femoral Bowing.” Hip & pelvis 30.4 (2018): 202-209.

Jeffrey Dach MD
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Published on January 6th, 2019 by
Jeffrey Dach MD

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